Amyloidosis: Difference between revisions

Amyloidosis
Amyloidosis
	Amyloidosis symptoms are often vague and require different physician specialists for diagnosis. Telltale symptoms may include an enlarged tongue (macroglossia) or bruising around the eyes (purpura)
Specialty	Internal medicine
Symptoms	Feeling tired, weight loss, swelling of the legs, shortness of breath, bleeding, feeling light headed with standing
Usual onset	55–65 years old
Causes	Genetic or acquired
Diagnostic method	Tissue biopsy
Treatment	Supportive care, directed at the underlying cause, dialysis, organ transplantation
Prognosis	Improved with treatment
Frequency	3–13 per million per year (AL amyloidosis)
Deaths	1 per 1,000 people (developed world)

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Amyloidosis is a group of diseases in which abnormal proteins, known as amyloid fibrils, build up in tissue.^[4] There are several non-specific and vague signs and symptoms associated with amyloidosis.^[5] These include fatigue, peripheral edema, weight loss, shortness of breath, palpitations, and feeling faint with standing.^[5] In AL amyloidosis, specific indicators can include enlargement of the tongue and periorbital purpura.^[5] In wild-type ATTR amyloidosis, non-cardiac symptoms include: bilateral carpal tunnel syndrome, lumbar spinal stenosis, biceps tendon rupture, small fiber neuropathy, and autonomic dysfunction.^[5]

There are about 36 different types of amyloidosis, each due to a specific protein misfolding.^[6] Within these 36 proteins, 19 are grouped into localized forms, 14 are grouped as systemic forms, and three proteins can identify as either.^[6] These proteins can become irregular due to genetic effects, as well as through acquired environmental factors.^[6] The four most common types of systemic amyloidosis are light chain (AL), inflammation (AA), dialysis-related (Aβ₂M), and hereditary and old age (ATTR and wild-type transthyretin amyloid^[7]).^[2]

Diagnosis may be suspected when protein is found in the urine, organ enlargement is present, or problems are found with multiple peripheral nerves and it is unclear why.^[2] Diagnosis is confirmed by tissue biopsy.^[2] Due to the variable presentation, a diagnosis can often take some time to reach.^[3]

Treatment is geared towards decreasing the amount of the involved protein.^[2] This may sometimes be achieved by determining and treating the underlying cause.^[2] AL amyloidosis occurs in about 3–13 per million people per year and AA amyloidosis in about two per million people per year.^[2] The usual age of onset of these two types is 55 to 60 years old.^[2] Without treatment, life expectancy is between six months and four years.^[2] In the developed world about one per 1,000 deaths are from systemic amyloidosis.^[3] Amyloidosis has been described since at least 1639.^[2]

Signs and symptoms

Skin features of amyloidosis cutis dyschromica. Hyperpigmented and hypopigmented macules on (A) lower legs, (B) back and waist, (C) waist. (D) Individual blisters on upper arm.

The presentation of amyloidosis is broad and depends on the site of amyloid accumulation. The kidney and heart are the most common organs involved.

Kidneys

Amyloid deposition in the kidney often involve the glomerular capillaries and mesangial regions, affecting the organ's ability to filter and excrete waste and retain plasma protein.^[8] This can lead to high levels of protein in the urine (proteinuria) and nephrotic syndrome.^[8] Several types of amyloidosis, including the AL and AA types, are associated with nephrotic syndrome.^[9] Approximately 20% and 40–60% of people with AL and AA amyloidosis respectively progress to end-stage kidney disease requiring dialysis.^[9]

Heart

Amyloid deposition in the heart can cause both diastolic and systolic heart failure. EKG changes may be present, showing low voltage and conduction abnormalities like atrioventricular block or sinus node dysfunction.^{[medical citation needed]} On echocardiography, the heart shows a restrictive filling pattern, with normal to mildly reduced systolic function.^[10] AA amyloidosis usually spares the heart.^[11] Cardiac amyloidosis can present with symptoms of heart failure including shortness of breath, fatigue, and edema.^[12] As cardiac amyloidosis progresses, the amyloid deposition can affect the heart's ability to pump and fill blood as well as its ability to maintain normal rhythm, which leads to worsening heart function and decline in people's quality of life.^[12]

Nervous system

People with amyloidosis may have central nervous system involvement,^[13] along with peripheral involvement which causes sensory and autonomic neuropathies. Sensory neuropathy develops in a symmetrical pattern and progresses in a distal to proximal manner. Autonomic neuropathy can present as orthostatic hypotension but may manifest more gradually with nonspecific gastrointestinal symptoms like constipation, nausea, or early satiety.^[10] Amyloidosis of the central nervous system can have more severe and systemic presentations that may include life-threatening arrhythmias, cardiac failure, malnutrition, infection, or death.^[14]

Neuropathic presentation can depend on the etiology of amyloidosis.^[14] People with amyloidosis may experience dysfunction in various organ systems depending on the location and extent of nervous system involvement.^[8] For example, peripheral neuropathy can cause erectile dysfunction, incontinence and constipation, pupillary dysfunction, and sensory loss depending on the distribution of amyloidosis along different peripheral nerves.^[14]

Gastrointestinal and accessory organs

Accumulation of amyloid proteins in the gastrointestinal system may be caused by a wide range of amyloid disorders and have different presentations depending on the degree of organ involvement.^[15] Potential symptoms include weight loss, diarrhea, abdominal pain, heartburn (gastrointestinal reflux), and GI bleeding.^[15] Amyloidosis may also affect accessory digestive organs including the liver, and may present with jaundice, fatty stool, anorexia, fluid buildup in the abdomen, and spleen enlargement.^[15]

Accumulation of amyloid proteins in the liver can lead to elevations in serum aminotransferases and alkaline phosphatase, two biomarkers of liver injury, which is seen in about one third of people.^[11] Liver enlargement is common. In contrast, spleen enlargement is rare, occurring in 5% of people.^[10] Splenic dysfunction, leading to the presence of Howell-Jolly bodies on blood smear, occurs in 24% of people with amyloidosis.^[10] Malabsorption is seen in 8.5% of AL amyloidosis and 2.4% of AA amyloidosis. One suggested mechanism for the observed malabsorption is that amyloid deposits in the tips of intestinal villi (fingerlike projections that increase the intestinal area available for absorption of food), begin to erode the functionality of the villi, presenting a sprue-like picture.^[11]

Glands

Both the thyroid and adrenal glands can be infiltrated. It is estimated that 10–20% of people with amyloidosis have hypothyroidism. Adrenal infiltration may be harder to appreciate given that its symptoms of orthostatic hypotension and low blood sodium concentration may be attributed to autonomic neuropathy and heart failure.^[10]

"Amyloid deposits occur in the pancreas of people who also have diabetes mellitus, although it is not known if this is functionally important. The major component of pancreatic amyloid is a 37-amino acid residue peptide known as islet amyloid polypeptide or 'amylin.' This is stored with insulin in secretory granules in [beta] cells and is co secreted with insulin." (Rang and Dale's Pharmacology, 2015.)^{[citation needed]}

Musculoskeletal system

Amyloid proteins deposit most commonly inside the knee, followed by hands, wrists, elbow, hip, and ankle, causing joint pain.^[16] In males with advanced age (>80 years), there is significant risk of wild-type transthyretin amyloid deposition in synovial tissue of knee joint, but predominantly in old age deposition of wild type transthyretin is seen in cardiac ventricles. ATTR deposits have been found in ligamentum flavum of patients that underwent surgery for lumbar spinal stenosis.^[17]

In beta 2-microglobulin amyloidosis, males have high risk of getting carpal tunnel syndrome.^[18] Aβ2MG amyloidosis (Hemodialysis associated amyloidosis) tends to deposit in synovial tissue, causing chronic inflammation of the synovial tissue in knee, hip, shoulder and interphalangeal joints.^[18] Amyloid light chains deposition in shoulder joint causes enlarged shoulders, also known as "shoulder pad sign".^[18] Amyloid light chain depositions can also cause bilateral symmetric polyarthritis.^[18]

The deposition of amyloid proteins in the bone marrow without causing plasma cell dyscrasias is called amyloidoma. It is commonly found in cervical, lumbar, and sacral vertebrae. Those affected may be presented with bone pain due to bone lysis, lumbar paraparesis, and a variety of neurological symptoms. Vertebral fractures are also common.^[18]

Eyes

A rare development is amyloid purpura, a susceptibility to bleeding with bruising around the eyes, termed "raccoon-eyes". Amyloid purpura is caused by amyloid deposition in the blood vessels and reduced activity of thrombin and factor X, two clotting proteins that lose their function after binding with amyloid.^[10]

Oral cavity

Amyloid deposits in tissue can cause enlargement of structures. Twenty percent of people with AL amyloidosis have an enlarged tongue, that can lead to obstructive sleep apnea, difficulty swallowing, and altered taste.^[11] Tongue enlargement does not occur in ATTR or AA amyloidosis.^[10] Deposition of amyloid in the throat can cause hoarseness.^[10]

Pathogenesis

Amyloidoses can be considered protein misfolding diseases.^[19]^[20] The vast majority of proteins that have been found to form amyloid deposits are secreted proteins, so the misfolding and formation of amyloid occurs outside cells, in the extracellular space.^[19] Of the 37 proteins so far identified as being vulnerable to amyloid formation, only four are cytosolic.^[19] Most amyloid-forming proteins are relatively small, but otherwise there is currently no evidence of structural or functional similarities among proteins known to form disease-associated amyloids.^[19] One third of amyloid disease is hereditary, in which case there is normally an early age of onset.^[19] Half of amyloid-related diseases are sporadic and have a late age of onset – in these cases, the protein aggregation may be associated with aging-related decline in protein regulation. Some medical treatments are associated with amyloid disease, but this is rare.^[19]

Amyloid-forming proteins aggregate into distinctive fibrillar forms with a beta-sheet structure.^[19]^[20] The beta-sheet form of amyloid is proteolysis-resistant, meaning it can not be degraded or broken down.^[5] As a result, amyloid deposits into the body's extracellular space.^[5] The process of forming amyloid fibrils is thought to have intermediate oligomeric forms. Both the oligomers and amyloid fibrils can be toxic to cells and can interfere with proper organ function.^[21] The relative significance of different aggregation species may depend on the protein involved and the organ system affected.^[20]

Diagnosis

Diagnosis of amyloidosis generally requires tissue biopsy.^[2] The biopsy is assessed for evidence of characteristic amyloid deposits. The tissue is treated with various stains. The most useful stain in the diagnosis of amyloid is Congo red, which, combined with polarized light, makes the amyloid proteins appear apple-green on microscopy. Also, thioflavin T stain may be used.^[22] A number of imaging techniques such as a Nuclear Medicine PYP scan, DPD scan or SAP scan are also in use.^[23]

A sample of tissue can be biopsied or obtained directly from the affected internal organ, but the first-line site of biopsy is subcutaneous abdominal fat, known as a "fat pad biopsy", due to its ease of acquisition.^[24]^[25] An abdominal fat biopsy is not completely sensitive and may result in false negatives, which means a negative result does not exclude the diagnosis of amyloidosis.^[24]^[25] However, direct biopsy of the affected organ may still be unnecessary as other less invasive methods of biopsy can also be used, including rectal mucosa, salivary gland, lip, or bone marrow biopsy which can achieve a diagnosis in up to 85% of people.^[24]

In the amyloid deposition of the joints, there will be a decreased signal in both T1 and T2 weighted MRI images.^[16] In amyloidoma, there will be low T1 signal with gadolinium injection and low T2 signal.^[18]

The type of the amyloid protein can be determined in various ways: the detection of abnormal proteins in the bloodstream (on protein electrophoresis or light chain determination); binding of particular antibodies to the amyloid found in the tissue (immunohistochemistry); or extraction of the protein and identification of its individual amino acids.^[22] Immunohistochemistry can identify AA amyloidosis the majority of the time, but can miss many cases of AL amyloidosis.^[11] Laser microdissection with mass spectrometry is the most reliable method of identifying the different forms of amyloidosis.^[26]

AL was previously considered the most common form of amyloidosis, and a diagnosis often begins with a search for plasma cell dyscrasia, memory B cells producing aberrant immunoglobulins or portions of immunoglobulins. Immunofixation electrophoresis of urine or serum is positive in 90% of people with AL amyloidosis.^[10] Immunofixation electrophoresis is more sensitive than regular electrophoresis but may not be available in all centers. Alternatively immunohistochemical staining of a bone marrow biopsy looking for dominant plasma cells can be sought in people with a high clinical suspicion for AL amyloidosis but negative electrophoresis.^[10]

ATTR is now considered to be the most common form of amyloidosis. It may be either age related in wild-type ATTR (ATTRv) or familial transthyretin-associated amyloidosis, is suspected in people with family history of idiopathic neuropathies or heart failure who lack evidence of plasma cell dyscrasias. ATTR can be identified using isoelectric focusing which separates mutated forms of transthyretin. Findings can be corroborated by genetic testing to look for specific known mutations in transthyretin that predispose to amyloidosis.^[10]

AA is suspected on clinical grounds in individuals with longstanding infections or inflammatory diseases. AA can be identified by immunohistochemistry staining.^[10]

Small bowel duodenum with amyloid deposition Congo red 10X
Amyloidosis, dystrophic calcification
Small bowel duodenum with amyloid deposition 20X
Amyloidosis, Node, Congo Red
Amyloidosis, blood vessels, H&E
Amyloidosis, lymph node, H&E
Amyloidosis, lymph node, polarizer
Cardiac amyloidosis. H&E stain.
Micrograph showing amyloid deposition (red fluffy material) in the heart (cardiac amyloidosis). Congo red stain.

Classification

Historical classification systems were based on clinical factors. Until the early 1970s, the idea of a single amyloid substance predominated. Various descriptive classification systems were proposed based on the organ distribution of amyloid deposits and clinical findings. Most classification systems included primary (i.e., idiopathic) amyloidosis, in which no associated clinical condition was identified, and secondary amyloidosis (i.e., secondary to chronic inflammatory conditions). Some classification systems included myeloma-associated, familial, and localized amyloidosis.^{[citation needed]}

The modern era of amyloidosis classification began in the late 1960s with the development of methods to make amyloid fibrils soluble. These methods permitted scientists to study the chemical properties of amyloids.^{[medical citation needed]} Descriptive terms such as primary amyloidosis, secondary amyloidosis, and others (e.g., senile amyloidosis), which are not based on cause, provide little useful information and are no longer recommended.

The modern classification of amyloid disease tends to use an abbreviation of the protein that makes the majority of deposits, prefixed with the letter A. For example, amyloidosis caused by transthyretin is termed "ATTR".^{[medical citation needed]} Deposition patterns vary between people but are almost always composed of just one amyloidogenic protein. Deposition can be systemic (affecting many different organ systems) or organ-specific. Many amyloidoses are inherited, due to mutations in the precursor protein.^{[medical citation needed]}

Other forms are due to different diseases causing overabundant or abnormal protein production – such as with overproduction of immunoglobulin light chains (termed AL amyloidosis), or with continuous overproduction of acute phase proteins in chronic inflammation (which can lead to AA amyloidosis).^{[medical citation needed]}

About 60 amyloid proteins have been identified so far.^[27] Of those, at least 36 have been associated with a human disease.^[28]

All amyloid fibril proteins start with the letter "A" followed by the protein suffix (and any applicable specification). See below for a list of amyloid fibril proteins which have been found in humans:^[29]

Fibril protein	Precursor protein	Target Organs	Systemic and/or localized	Acquired or hereditary
AL	Immunoglobulin light chain	All organs, usually except CNS	S, L	A, H
AH	Immunoglobulin heavy chain	All organs except CNS	S, L	A
AA	(Apo) serum amyloid A	All organs except CNS	S	A
ATTR	Transthyretin, wild type Transthyretin, variants	Heart mainly in males, lung, ligaments, tenosynovium PNS, ANS, heart, eye, leptomeninges	S S	A H
Aβ2M	β2-microglobulin, wild type β2-microglobulin, variants	Musculoskeletal system ANS	S S	A H
AApoAI	Apolipoprotein A I, variants	Heart, liver, kidney, PNS, testis, larynx (C terminal variants), skin (C terminal variants)	S	H
AApoAII	Apolipoprotein A II, variants	Kidney	S	H
AApoAIV	Apolipoprotein A IV, wild type	Kidney medulla and systemic	S	A
AApoCII	Apolipoprotein C II, variants	Kidney	S	H
AApoCIII	Apolipoprotein C III, variants	Kidney	S	H
AGel	Gelsolin, variants	Kidney, PNS, cornea	S	H
ALys	Lysozyme, variants	Kidney	S	H
ALECT2	Leukocyte chemotactic factor-2	Kidney, primarily	S	A
AFib	Fibrinogen a, variants	Kidney, primarily	S	H
ACys	Cystatin C, variants	CNS, PNS, skin	S	H
ABri	ABriPP, variants	CNS	S	H
ADan^b	ADanPP, variants	CNS	L	H
Aβ	Aβ protein precursor, wild type Aβ protein precursor, variant	CNS CNS	L L	A H
AαSyn	α-Synuclein	CNS	L	A
ATau	Tau	CNS	L	A
APrP	Prion protein, wild type Prion protein variants Prion protein variant	CJD, fatal insomnia CJD, GSS syndrome, fatal insomnia PNS	L L S	A H H
ACal	(Pro)calcitonin	C-cell thyroid tumours Kidney	L S	A A
AIAPP	Islet amyloid polypeptide^c	Islets of Langerhans, insulinomas	L	A
AANF	Atrial natriuretic factor	Cardiac atria	L	A
APro	Prolactin	Pituitary prolactinomas, aging pituitary	L	A
AIns	Insulin	Iatrogenic, local injection	L	A
ASPC^d	Lung surfactant protein	Lung	L	A
ACor	Corneodesmosin	Cornified epithelia, hair follicles	L	A
AMed	Lactadherin	Senile aortic, media	L	A
AKer	Kerato-epithelin	Cornea, hereditary	L	A
ALac	Lactoferrin	Cornea	L	A
AOAAP	Odontogenic ameloblast-associated protein	Odontogenic tumours	L	A
ASem1	Semenogelin 1	Vesicula seminalis	L	A
AEnf	Enfurvitide	Iatrogenic	L	A
ACatK^e	Cathepsin K	Tumour associated	L	A
AEFEMP1^e	EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP1)	Portal veins, Aging associated	L	A

Alternative

An older clinical method of classification refers to amyloidoses as systemic or localised:

Systemic amyloidoses affect more than one body organ or system. Examples are AL, AA and Aβ2m.^[30]
Localised amyloidoses affect only one body organ or tissue type. Examples are Aβ, IAPP, Atrial natriuretic factor (in isolated atrial amyloidosis), and Calcitonin (in medullary carcinoma of the thyroid)^[30]

Another classification is primary or secondary.^{[medical citation needed]}

Primary amyloidoses arise from a disease with disordered immune cell function, such as multiple myeloma or other immunocyte dyscrasias.
Secondary (reactive) amyloidoses occur as a complication of some other chronic inflammatory or tissue-destroying disease. Examples are reactive systemic amyloidosis and secondary cutaneous amyloidosis.^[30]

Additionally, based on the tissues in which it is deposited, it is divided into mesenchymal (organs derived from mesoderm) or parenchymal (organs derived from ectoderm or endoderm).^{[medical citation needed]}

Treatment

Treatment depends on the type of amyloidosis that is present. Treatment with high dose melphalan, a chemotherapy agent, followed by stem cell transplantation has shown promise in early studies and is recommended for stage I and II AL amyloidosis.^[26] However, only 20–25% of people are eligible for stem cell transplant. Chemotherapy treatment including cyclophosphamide-bortezomib-dexamethasone is currently the recommended treatment option for people with AL Amyloidosis not eligible for transplant.^[5]

In AA, symptoms may improve if the underlying condition is treated. In people who have inflammation caused by AA amyloidosis, tumour necrosis factor (TNF)-alpha inhibitors such as infliximab and etanercept are used for an average duration of 20 months. If TNF-alpha inhibitors are not effective, Interleukin-1 inhibitors (e.g., anakinra, canakinumab, rilonacept) and interleukin-6 inhibitors (e.g., tocilizumab) may be considered.^[31]

Management of ATTR amyloidosis will depend on its classification as wild type or variant.^[5] Both may be treated with tafamidis, a low toxicity oral agent that prevents destabilization of correctly folded protein.^[5] Studies showed tafamidis reduced mortality and hospitalization due to heart failure.^[5] Previously, for variant ATTR amyloidosis, liver transplant was the only effective treatment.^[5] New therapies include diflunisal, inotersen, and patisiran.

Diflunisal binds to misfolded mutant TTR protein to prevent its buildup, like how tafamidis works. Low-certainty evidence indicates that it mitigates worsening of peripheral neuropathy and disability from disease progression.^[32]

Inotersen blocks gene expression of both wild-type and mutant TTR, reducing amyloid precursor. Moderate-certainty evidence suggests that it mitigates worsening of peripheral neuropathy. Long-term efficacy and safety of inotersen use in people with mutant TTR-related amyloidosis is still be evaluated in a phase-III clinical trial as of 2021. Both diflunisal and inotersen may also mitigate declines in quality-of-life, though the evidence for this effect is unclear.^[32] For people with cardiac ATTR the effect of inotersen use is inconclusive and requires further investigation.^[33] In 2018, inotersen was approved by the European Medicines Agency to treat polyneuropathy in adults with hereditary transthyretin amyloidosis.^[34] It has since been approved for use in Canada, the European Union and in the USA.^[35]

Patisiran functions similarly to inotersen. Moderate-certainty evidence suggests that patisiran mitigates worsening of peripheral neuropathy and disability from disease progression. Additionally, low-certainty evidence suggests that patisiran mitigates decreases in quality-of-life and slightly reduces the rate of adverse events versus placebo. There is no evidence of an effect on mortality rate.^[32] A review of early data from use of patisiran in people with variant cardiac ATTR suggests that it may reduce mortality and hospitalization, however this is still being investigated and requires further investigation.^[33] In 2018, patisiran was not recommended by NICE in the UK for hereditary transthyretin-related amyloidosis.^[36] As of July 2019 further review however is occurring.^[37] It was approved for this use in the United States, however.^[38]

The roles of inotersen and patisiran in cardiac ATTR amyloidosis are still being investigated.^[5]

In 2021, in a clinical trial using the CRISPR gene-editing technique, several participants had an "80% to 96% drop in TTR levels, on par or better than the average of 81%" who were given patisiran.^[39]

Vutrisiran was approved by the U.S. Food and Drug Administration (FDA) in June 2022, for the treatment of the polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults.^[40]

Support groups

People affected by amyloidosis are supported by organizations, including the Amyloidosis Research Consortium, Amyloidosis Foundation, Amyloidosis Support Groups, and Australian Amyloidosis Network.^[41]^[42]

Prognosis

Prognosis varies with the type of amyloidosis and the affected organ system. Prognosis for untreated AL cardiac amyloidosis is poor, with a median survival of six months.^[43] More specifically, AL amyloidosis can be classified as stage I, II or III based on cardiac biomarkers like Nt-proBNP and cardiac troponin.^[44] Survival diminishes with increasing stage, but recent advancements in treatments have improved median survival rates for stages I, II, and III, to 91.2, 60, and 7 months respectively.^[44]

Outcomes in a person with AA amyloidosis depend on the underlying disease, organ(s) affected, and correlate with the concentration of serum amyloid A protein.^[5]

People with ATTR, mutant ATTR and wild-type ATTR have a better prognosis when compared to people with AL and may survive for over a decade.^[10]^[45] Survival time is not associated with gender or age, however, some measures of reduced heart function are associated with a shorter survival time.^[45]

Senile systemic amyloidosis was determined to be the primary cause of death for 70% of people over 110 who have been autopsied.^[46]^[47]

Epidemiology

Amyloidosis has a combined estimated prevalence of 30 per 100,000 persons with the three most common forms being AL, ATTR, and AA.^[48] The median age at diagnosis is 64.^[11]

AL has the highest incidence at approximately 12 cases per million persons per year and an estimated prevalence of 30,000 to 45,000 cases in the US and European Union.^[48]^[5]

AA amyloidoses is the most common form in developing countries and can complicate longstanding infections with tuberculosis, osteomyelitis, and bronchiectasis. AA amyloidosis is caused by an increase in extracellular deposition of serum amyloid A (SAA) protein. SAA protein levels can rise in both direct and indirect manners, through infection, inflammation, and malignancies.^[49] The most common causes of AA amyloidosis in the West are rheumatoid arthritis, inflammatory bowel disease, psoriasis, and familial Mediterranean fever.^[10]

People undergoing long-term hemodialysis (14–15 years) can develop amyloidosis from accumulation of light chains of the HLA 1 complex which is normally filtered out by the kidneys.^[11]

Wild-type transthyretin (ATTR) amyloidosis is found in a quarter of elderly at postmortem.^[50] ATTR is found in 13–19% of people experiencing heart failure with preserved ejection fraction, making it a very common form of systemic amyloidosis.^[51]

Research

Treatments for ATTR-related neuropathy include TTR-specific oligonucleotides in the form of small interfering RNA (patisiran) or antisense inotersen,^[52] the former having recently received FDA approval.^[53] Research into treatments for ATTR amyloidosis have compared liver transplantation, oral drugs that stabilize the misfolding protein (including tafamidis and diflunisal), and newer therapeutic agents still being investigated (including patisiran).^[54]

Based on available research, liver transplant remains the most effective treatment option for advanced ATTR amyloidosis, protein stabilizing drugs may slow disease progression but were insufficient to justify delay of liver transplant, and newer agents such as patisiran require additional studies.^[54]

References

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^ ^a ^b ^c ^d ^e ^f Nguyen TX, Naqvi A, Thompson TL, Wilson RH (Spring 2018). "Musculoskeletal Manifestations of Amyloidosis: A Focused Review". Journal of Surgical Orthopaedic Advances. 27 (1): 1–5. PMID 29762107.
^ ^a ^b ^c ^d ^e ^f ^g Chiti F, Dobson CM (June 2017). "Protein Misfolding, Amyloid Formation, and Human Disease: A Summary of Progress Over the Last Decade". Annual Review of Biochemistry. 86: 27–68. doi:10.1146/annurev-biochem-061516-045115. hdl:2158/1117236. PMID 28498720.
^ ^a ^b ^c Merlini G, Seldin DC, Gertz MA (May 2011). "Amyloidosis: pathogenesis and new therapeutic options". Journal of Clinical Oncology. 29 (14): 1924–1933. doi:10.1200/JCO.2010.32.2271. PMC 3138545. PMID 21483018.
^ Gertz MA, Rajkumar SV (2010). Amyloidosis. Totowa, N.J.: Humana. ISBN 978-1-60761-631-3. OCLC 654382006.
^ ^a ^b Dember LM (December 2006). "Amyloidosis-associated kidney disease". Journal of the American Society of Nephrology. 17 (12): 3458–3471. doi:10.1681/ASN.2006050460. PMID 17093068. Archived from the original on 5 December 2011.
^ Sachchithanantham S, Wechalekar AD (2013). "Imaging in systemic amyloidosis". British Medical Bulletin. 107: 41–56. doi:10.1093/bmb/ldt021. PMID 23896486.
^ ^a ^b ^c Merlini G, Dispenzieri A, Sanchorawala V, Schönland SO, Palladini G, Hawkins PN, Gertz MA (October 2018). "Systemic immunoglobulin light chain amyloidosis". Nature Reviews. Disease Primers. 4 (1): 38. doi:10.1038/s41572-018-0034-3. PMID 30361521. S2CID 53023121. Archived from the original on 14 June 2022. Retrieved 25 December 2020.
^ ^a ^b Wechalekar AD, Gillmore JD, Hawkins PN (June 2016). "Systemic amyloidosis". Lancet. 387 (10038): 2641–2654. doi:10.1016/S0140-6736(15)01274-X. PMID 26719234. S2CID 4762107.
^ ^a ^b Rosenzweig M, Landau H (November 2011). "Light chain (AL) amyloidosis: update on diagnosis and management". Journal of Hematology & Oncology. 4 (1): 47. doi:10.1186/1756-8722-4-47. PMC 3228694. PMID 22100031.
^ Mok KH, Pettersson J, Orrenius S, Svanborg C (March 2007). "HAMLET, protein folding, and tumor cell death". Biochemical and Biophysical Research Communications. 354 (1): 1–7. doi:10.1016/j.bbrc.2006.12.167. PMID 17223074.
^ Pettersson-Kastberg J, Aits S, Gustafsson L, Mossberg A, Storm P, Trulsson M, et al. (November 2008). "Can misfolded proteins be beneficial? The HAMLET case". Annals of Medicine. 41 (3): 162–176. doi:10.1080/07853890802502614. PMID 18985467. S2CID 31198109.
^ Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJ, Sekijima Y, et al. (December 2020). "Amyloid nomenclature 2020: update and recommendations by the International Society of Amyloidosis (ISA) nomenclature committee". Amyloid. 27 (4): 217–222. doi:10.1080/13506129.2020.1835263. PMID 33100054. S2CID 225073269.
^ ^a ^b ^c Table 5-12 in: Mitchell RS, Kumar V, Abbas AK, Fausto N (2007). Robbins Basic Pathology. Philadelphia: Saunders. ISBN 978-1-4160-2973-1. 8th edition.
^ ter Haar NM, Oswald M, Jeyaratnam J, Anton J, Barron KS, Brogan PA, et al. (September 2015). "Recommendations for the management of autoinflammatory diseases". Annals of the Rheumatic Diseases. 74 (9): 1636–1644. doi:10.1136/annrheumdis-2015-207546. hdl:2445/108897. PMID 26109736. S2CID 18876892.
^ ^a ^b ^c Magrinelli F, Fabrizi GM, Santoro L, Manganelli F, Zanette G, Cavallaro T, Tamburin S, et al. (Cochrane Neuromuscular Group) (April 2020). "Pharmacological treatment for familial amyloid polyneuropathy". The Cochrane Database of Systematic Reviews. 4 (4): CD012395. doi:10.1002/14651858.CD012395.pub2. PMC 7170468. PMID 32311072.
^ ^a ^b Marques N, Azevedo O, Almeida AR, Bento D, Cruz I, Correia E, et al. (October 2020). "Specific Therapy for Transthyretin Cardiac Amyloidosis: A Systematic Literature Review and Evidence-Based Recommendations". Journal of the American Heart Association. 9 (19): e016614. doi:10.1161/JAHA.120.016614. PMC 7792401. PMID 32969287.
^ "Tegsedi". Europeans Medicines Agency. Archived from the original on 8 October 2020. Retrieved 12 March 2021.
^ Mathew V, Wang AK (6 May 2019). "Inotersen: new promise for the treatment of hereditary transthyretin amyloidosis". Drug Design, Development and Therapy. 13: 1515–1525. doi:10.2147/DDDT.S162913. PMC 6507904. PMID 31118583.
^ "Patisiran for treating hereditary transthyretinrelated amyloidosis". Archived from the original on 4 July 2019. Retrieved 20 July 2019.
^ "Patisiran for treating hereditary transthyretin-related amyloidosis [ID1279] | Guidance | NICE". National Institute for Health and Care Excellence (Nice). Archived from the original on 20 July 2019. Retrieved 20 July 2019.
^ Hoy SM (October 2018). "Patisiran: First Global Approval". Drugs. 78 (15): 1625–1631. doi:10.1007/s40265-018-0983-6. PMID 30251172. S2CID 52813638.
^ Gillmore JD, Gane E, Taubel J, Kao J, Fontana M, Maitland ML, et al. (August 2021). "CRISPR-Cas9 In Vivo Gene Editing for Transthyretin Amyloidosis". The New England Journal of Medicine. 385 (6): 493–502. doi:10.1056/NEJMoa2107454. PMID 34215024. S2CID 235722446.
^ "Alnylam Announces FDA Approval of Amvuttra (vutrisiran), an RNAi Therapeutic for the Treatment of the Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis in Adults". Alnylam. 13 June 2022. Archived from the original on 14 June 2022. Retrieved 14 June 2022 – via Business Wire.
^ "Amyloidosis - NORD (National Organization for Rare Disorders)". NORD (National Organization for Rare Disorders). Archived from the original on 16 March 2016. Retrieved 15 March 2016.
^ "Amyloidosis primary cutaneous – Disease – Organizations – Genetic and Rare Diseases Information Center (GARD) – NCATS Program". rarediseases.info.nih.gov. Archived from the original on 15 March 2016. Retrieved 15 March 2016.
^ Merlini G (December 2017). "AL amyloidosis: from molecular mechanisms to targeted therapies". Hematology. American Society of Hematology. Education Program. 2017 (1): 1–12. doi:10.1182/asheducation-2017.1.1. PMC 6142527. PMID 29222231.
^ ^a ^b Falk RH, Alexander KM, Liao R, Dorbala S (September 2016). "AL (Light-Chain) Cardiac Amyloidosis: A Review of Diagnosis and Therapy". Journal of the American College of Cardiology. 68 (12): 1323–1341. doi:10.1016/j.jacc.2016.06.053. PMID 27634125.
^ ^a ^b Xin Y, Hu W, Chen X, Hu J, Sun Y, Zhao Y (November 2019). "Prognostic impact of light-chain and transthyretin-related categories in cardiac amyloidosis: A systematic review and meta-analysis". Hellenic Journal of Cardiology. 60 (6): 375–383. doi:10.1016/j.hjc.2019.01.015. PMID 30742933. S2CID 73419672.
^ Coles LS, Young RD (May 2012). "Supercentenarians and transthyretin amyloidosis: the next frontier of human life extension". Preventive Medicine. 54 (Suppl): S9-11. doi:10.1016/j.ypmed.2012.03.003. PMID 22579241.
^ "Searching for the Secrets of the Super Old". Science. 26 September 2008. pp. 1764–1765. Archived from the original on 9 March 2013. Retrieved 22 February 2013.
^ ^a ^b Lin HM, Gao X, Cooke CE, Berg D, Labotka R, Faller DV, et al. (June 2017). "Disease burden of systemic light-chain amyloidosis: a systematic literature review". Current Medical Research and Opinion. 33 (6): 1017–1031. doi:10.1080/03007995.2017.1297930. PMID 28277869. S2CID 205541963.
^ Brunger AF, Nienhuis HL, Bijzet J, Hazenberg BP (March 2020). "Causes of AA amyloidosis: a systematic review". Amyloid. 27 (1): 1–12. doi:10.1080/13506129.2019.1693359. PMID 31766892. S2CID 208299494.
^ Tanskanen M, Peuralinna T, Polvikoski T, Notkola IL, Sulkava R, Hardy J, Singleton A, Kiuru-Enari S, Paetau A, Tienari PJ, Myllykangas L (1 January 2008). "Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2-macroglobulin and tau: A population-based autopsy study". Annals of Medicine. 40 (3): 232–239. doi:10.1080/07853890701842988. ISSN 0785-3890. PMID 18382889. S2CID 23446885. Archived from the original on 14 June 2022. Retrieved 18 March 2022.
^ Hasib Sidiqi M, Gertz MA (May 2021). "Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021". Blood Cancer Journal. 11 (5): 90. doi:10.1038/s41408-021-00483-7. PMC 8124067. PMID 33993188.
^ Buxbaum JN (July 2018). "Oligonucleotide Drugs for Transthyretin Amyloidosis". The New England Journal of Medicine. 379 (1): 82–85. doi:10.1056/nejme1805499. PMID 29972750. S2CID 49658028.
^ Office of the Commissioner. "Press Announcements - FDA approves first-of-its kind targeted RNA-based therapy to treat a rare disease". www.fda.gov. Archived from the original on 7 September 2018. Retrieved 11 August 2018.
^ ^a ^b Cristóbal Gutiérrez H, Pelayo-Negro AL, Gómez Gómez D, Martín Vega MÁ, Valero Domínguez M (July 2020). "Overview of treatments used in transthyretin-related hereditary amyloidosis: a systematic review". European Journal of Hospital Pharmacy. 27 (4): 194–201. doi:10.1136/ejhpharm-2018-001823. PMC 7335620. PMID 32587078.

External links

[1] "Amyloidosis Awareness" (PDF). amyloidaware.com. Amyloidosis Support Groups. 1 March 2022. Retrieved 15 June 2024.

[Haz2013-2] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ Hazenberg BP (May 2013). "Amyloidosis: a clinical overview" (PDF). Rheumatic Disease Clinics of North America. 39 (2): 323–345. doi:10.1016/j.rdc.2013.02.012. PMID 23597967. S2CID 215069282.

[Pep2006-3] ^ ^a ^b ^c ^d ^e ^f Pepys MB (2006). "Amyloidosis". Annual Review of Medicine. 57: 223–241. doi:10.1146/annurev.med.57.121304.131243. PMID 16409147.

[4] "AL amyloidosis". rarediseases.info.nih.gov. Genetic and Rare Diseases Information Center (GARD). Archived from the original on 24 April 2017. Retrieved 22 April 2017.

[Gertz_2020-5] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ Gertz MA, Dispenzieri A (July 2020). "Systemic Amyloidosis Recognition, Prognosis, and Therapy: A Systematic Review". JAMA. 324 (1): 79–89. doi:10.1001/jama.2020.5493. PMID 32633805. S2CID 220385853.

[Picken_2020-6] Picken MM (2020). "The Pathology of Amyloidosis in Classification: A Review". Acta Haematologica. 143 (4): 322–334. doi:10.1159/000506696. PMID 32392555. S2CID 218600304.

[Ando2020-7] Ando Y, Coelho T, Berk JL, Cruz MW, Ericzon BG, Ikeda S, et al. (February 2013). "Guideline of transthyretin-related hereditary amyloidosis for clinicians". Orphanet Journal of Rare Diseases. 8: 31. doi:10.1186/1750-1172-8-31. PMC 3584981. PMID 23425518.

[niddk-8] "Amyloidosis & Kidney Disease". National Institute of Diabetes and Digestive and Kidney Diseases. U.S. Department of Health and Human Services. Archived from the original on 19 November 2021. Retrieved 19 November 2021.

[Lewis_2018-9] Lewis JB, Neilson EG (2018). "Glomerular Diseases". In Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J (eds.). Harrison's Principles of Internal Medicine (20 ed.). McGraw Hill. Archived from the original on 29 November 2021. Retrieved 29 November 2021.

[Falk_1997-10] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ Falk RH, Comenzo RL, Skinner M (September 1997). "The systemic amyloidoses". The New England Journal of Medicine. 337 (13): 898–909. doi:10.1056/NEJM199709253371306. PMID 9302305.

[Ebert_2008-11] ^ ^a ^b ^c ^d ^e ^f ^g Ebert EC, Nagar M (March 2008). "Gastrointestinal manifestations of amyloidosis". The American Journal of Gastroenterology. 103 (3): 776–787. doi:10.1111/j.1572-0241.2007.01669.x. PMID 18076735. S2CID 25431033.

[Kyriakou_2018-12] Kyriakou P, Mouselimis D, Tsarouchas A, Rigopoulos A, Bakogiannis C, Noutsias M, Vassilikos V (December 2018). "Diagnosis of cardiac amyloidosis: a systematic review on the role of imaging and biomarkers". BMC Cardiovascular Disorders. 18 (1): 221. doi:10.1186/s12872-018-0952-8. PMC 6278059. PMID 30509186.

[13] Soprano DR, Herbert J, Soprano KJ, Schon EA, Goodman DS. Demonstration of transthyretin mRNA in the brain and other extrahepatic tissues in the rat. J Biol Chem 1985; 260 (21) 11793-11798

[Kaku_2019-14] Kaku M, Berk JL (October 2019). "Neuropathy Associated with Systemic Amyloidosis". Seminars in Neurology. 39 (5): 578–588. doi:10.1055/s-0039-1688994. PMID 31639841. S2CID 204850185.

[Rowe_2017-15] Rowe K, Pankow J, Nehme F, Salyers W (May 2017). "Gastrointestinal Amyloidosis: Review of the Literature". Cureus. 9 (5): e1228. doi:10.7759/cureus.1228. PMC 5464793. PMID 28611935.

[Takahashi_2016-16] Takahashi N, Glockner J, Howe BM, Hartman RP, Kawashima A (May 2016). "Taxonomy and Imaging Manifestations of Systemic Amyloidosis". Radiologic Clinics of North America. 54 (3): 597–612. doi:10.1016/j.rcl.2015.12.012. PMID 27153791.

[17] Eldhagen P, Berg S, Lund LH, Sörensson P, Suhr OB, Westermark P (June 2021). "Transthyretin amyloid deposits in lumbar spinal stenosis and assessment of signs of systemic amyloidosis". Journal of Internal Medicine. 289 (6): 895–905. doi:10.1111/joim.13222. ISSN 1365-2796. PMC 8248398. PMID 33274477.

[Nguyen_2018-18] ^ ^a ^b ^c ^d ^e ^f Nguyen TX, Naqvi A, Thompson TL, Wilson RH (Spring 2018). "Musculoskeletal Manifestations of Amyloidosis: A Focused Review". Journal of Surgical Orthopaedic Advances. 27 (1): 1–5. PMID 29762107.

[Chiti_2017-19] ^ ^a ^b ^c ^d ^e ^f ^g Chiti F, Dobson CM (June 2017). "Protein Misfolding, Amyloid Formation, and Human Disease: A Summary of Progress Over the Last Decade". Annual Review of Biochemistry. 86: 27–68. doi:10.1146/annurev-biochem-061516-045115. hdl:2158/1117236. PMID 28498720.

[Merlini_2011-20] Merlini G, Seldin DC, Gertz MA (May 2011). "Amyloidosis: pathogenesis and new therapeutic options". Journal of Clinical Oncology. 29 (14): 1924–1933. doi:10.1200/JCO.2010.32.2271. PMC 3138545. PMID 21483018.

[21] Gertz MA, Rajkumar SV (2010). Amyloidosis. Totowa, N.J.: Humana. ISBN 978-1-60761-631-3. OCLC 654382006.

[Dember2006-22] Dember LM (December 2006). "Amyloidosis-associated kidney disease". Journal of the American Society of Nephrology. 17 (12): 3458–3471. doi:10.1681/ASN.2006050460. PMID 17093068. Archived from the original on 5 December 2011.

[23] Sachchithanantham S, Wechalekar AD (2013). "Imaging in systemic amyloidosis". British Medical Bulletin. 107: 41–56. doi:10.1093/bmb/ldt021. PMID 23896486.

[Merlini_2018-24] Merlini G, Dispenzieri A, Sanchorawala V, Schönland SO, Palladini G, Hawkins PN, Gertz MA (October 2018). "Systemic immunoglobulin light chain amyloidosis". Nature Reviews. Disease Primers. 4 (1): 38. doi:10.1038/s41572-018-0034-3. PMID 30361521. S2CID 53023121. Archived from the original on 14 June 2022. Retrieved 25 December 2020.

[Wechalekar_2016-25] Wechalekar AD, Gillmore JD, Hawkins PN (June 2016). "Systemic amyloidosis". Lancet. 387 (10038): 2641–2654. doi:10.1016/S0140-6736(15)01274-X. PMID 26719234. S2CID 4762107.

[Rosenzweig_2011-26] Rosenzweig M, Landau H (November 2011). "Light chain (AL) amyloidosis: update on diagnosis and management". Journal of Hematology & Oncology. 4 (1): 47. doi:10.1186/1756-8722-4-47. PMC 3228694. PMID 22100031.

[pmid17223074-27] Mok KH, Pettersson J, Orrenius S, Svanborg C (March 2007). "HAMLET, protein folding, and tumor cell death". Biochemical and Biophysical Research Communications. 354 (1): 1–7. doi:10.1016/j.bbrc.2006.12.167. PMID 17223074.

[pmid18985467-28] Pettersson-Kastberg J, Aits S, Gustafsson L, Mossberg A, Storm P, Trulsson M, et al. (November 2008). "Can misfolded proteins be beneficial? The HAMLET case". Annals of Medicine. 41 (3): 162–176. doi:10.1080/07853890802502614. PMID 18985467. S2CID 31198109.

[29] Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJ, Sekijima Y, et al. (December 2020). "Amyloid nomenclature 2020: update and recommendations by the International Society of Amyloidosis (ISA) nomenclature committee". Amyloid. 27 (4): 217–222. doi:10.1080/13506129.2020.1835263. PMID 33100054. S2CID 225073269.

[Kumar5-12-30] Table 5-12 in: Mitchell RS, Kumar V, Abbas AK, Fausto N (2007). Robbins Basic Pathology. Philadelphia: Saunders. ISBN 978-1-4160-2973-1. 8th edition.

[31] ter Haar NM, Oswald M, Jeyaratnam J, Anton J, Barron KS, Brogan PA, et al. (September 2015). "Recommendations for the management of autoinflammatory diseases". Annals of the Rheumatic Diseases. 74 (9): 1636–1644. doi:10.1136/annrheumdis-2015-207546. hdl:2445/108897. PMID 26109736. S2CID 18876892.

[Magrinelli_2020-32] Magrinelli F, Fabrizi GM, Santoro L, Manganelli F, Zanette G, Cavallaro T, Tamburin S, et al. (Cochrane Neuromuscular Group) (April 2020). "Pharmacological treatment for familial amyloid polyneuropathy". The Cochrane Database of Systematic Reviews. 4 (4): CD012395. doi:10.1002/14651858.CD012395.pub2. PMC 7170468. PMID 32311072.

[Marques_2020-33] Marques N, Azevedo O, Almeida AR, Bento D, Cruz I, Correia E, et al. (October 2020). "Specific Therapy for Transthyretin Cardiac Amyloidosis: A Systematic Literature Review and Evidence-Based Recommendations". Journal of the American Heart Association. 9 (19): e016614. doi:10.1161/JAHA.120.016614. PMC 7792401. PMID 32969287.

[34] "Tegsedi". Europeans Medicines Agency. Archived from the original on 8 October 2020. Retrieved 12 March 2021.

[35] Mathew V, Wang AK (6 May 2019). "Inotersen: new promise for the treatment of hereditary transthyretin amyloidosis". Drug Design, Development and Therapy. 13: 1515–1525. doi:10.2147/DDDT.S162913. PMC 6507904. PMID 31118583.

[36] "Patisiran for treating hereditary transthyretinrelated amyloidosis". Archived from the original on 4 July 2019. Retrieved 20 July 2019.

[37] "Patisiran for treating hereditary transthyretin-related amyloidosis [ID1279] | Guidance | NICE". National Institute for Health and Care Excellence (Nice). Archived from the original on 20 July 2019. Retrieved 20 July 2019.

[38] Hoy SM (October 2018). "Patisiran: First Global Approval". Drugs. 78 (15): 1625–1631. doi:10.1007/s40265-018-0983-6. PMID 30251172. S2CID 52813638.

[39] Gillmore JD, Gane E, Taubel J, Kao J, Fontana M, Maitland ML, et al. (August 2021). "CRISPR-Cas9 In Vivo Gene Editing for Transthyretin Amyloidosis". The New England Journal of Medicine. 385 (6): 493–502. doi:10.1056/NEJMoa2107454. PMID 34215024. S2CID 235722446.

[Alnylam_PR_20220613-40] "Alnylam Announces FDA Approval of Amvuttra (vutrisiran), an RNAi Therapeutic for the Treatment of the Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis in Adults". Alnylam. 13 June 2022. Archived from the original on 14 June 2022. Retrieved 14 June 2022 – via Business Wire.

[41] "Amyloidosis - NORD (National Organization for Rare Disorders)". NORD (National Organization for Rare Disorders). Archived from the original on 16 March 2016. Retrieved 15 March 2016.

[42] "Amyloidosis primary cutaneous – Disease – Organizations – Genetic and Rare Diseases Information Center (GARD) – NCATS Program". rarediseases.info.nih.gov. Archived from the original on 15 March 2016. Retrieved 15 March 2016.

[43] Merlini G (December 2017). "AL amyloidosis: from molecular mechanisms to targeted therapies". Hematology. American Society of Hematology. Education Program. 2017 (1): 1–12. doi:10.1182/asheducation-2017.1.1. PMC 6142527. PMID 29222231.

[Falk_2016-44] Falk RH, Alexander KM, Liao R, Dorbala S (September 2016). "AL (Light-Chain) Cardiac Amyloidosis: A Review of Diagnosis and Therapy". Journal of the American College of Cardiology. 68 (12): 1323–1341. doi:10.1016/j.jacc.2016.06.053. PMID 27634125.

[Xin_2019-45] Xin Y, Hu W, Chen X, Hu J, Sun Y, Zhao Y (November 2019). "Prognostic impact of light-chain and transthyretin-related categories in cardiac amyloidosis: A systematic review and meta-analysis". Hellenic Journal of Cardiology. 60 (6): 375–383. doi:10.1016/j.hjc.2019.01.015. PMID 30742933. S2CID 73419672.

[46] Coles LS, Young RD (May 2012). "Supercentenarians and transthyretin amyloidosis: the next frontier of human life extension". Preventive Medicine. 54 (Suppl): S9-11. doi:10.1016/j.ypmed.2012.03.003. PMID 22579241.

[47] "Searching for the Secrets of the Super Old". Science. 26 September 2008. pp. 1764–1765. Archived from the original on 9 March 2013. Retrieved 22 February 2013.

[Lin_2017-48] Lin HM, Gao X, Cooke CE, Berg D, Labotka R, Faller DV, et al. (June 2017). "Disease burden of systemic light-chain amyloidosis: a systematic literature review". Current Medical Research and Opinion. 33 (6): 1017–1031. doi:10.1080/03007995.2017.1297930. PMID 28277869. S2CID 205541963.

[49] Brunger AF, Nienhuis HL, Bijzet J, Hazenberg BP (March 2020). "Causes of AA amyloidosis: a systematic review". Amyloid. 27 (1): 1–12. doi:10.1080/13506129.2019.1693359. PMID 31766892. S2CID 208299494.

[50] Tanskanen M, Peuralinna T, Polvikoski T, Notkola IL, Sulkava R, Hardy J, Singleton A, Kiuru-Enari S, Paetau A, Tienari PJ, Myllykangas L (1 January 2008). "Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2-macroglobulin and tau: A population-based autopsy study". Annals of Medicine. 40 (3): 232–239. doi:10.1080/07853890701842988. ISSN 0785-3890. PMID 18382889. S2CID 23446885. Archived from the original on 14 June 2022. Retrieved 18 March 2022.

[51] Hasib Sidiqi M, Gertz MA (May 2021). "Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021". Blood Cancer Journal. 11 (5): 90. doi:10.1038/s41408-021-00483-7. PMC 8124067. PMID 33993188.

[52] Buxbaum JN (July 2018). "Oligonucleotide Drugs for Transthyretin Amyloidosis". The New England Journal of Medicine. 379 (1): 82–85. doi:10.1056/nejme1805499. PMID 29972750. S2CID 49658028.

[53] Office of the Commissioner. "Press Announcements - FDA approves first-of-its kind targeted RNA-based therapy to treat a rare disease". www.fda.gov. Archived from the original on 7 September 2018. Retrieved 11 August 2018.

[Cristóbal_Gutiérrez_2020-54] Cristóbal Gutiérrez H, Pelayo-Negro AL, Gómez Gómez D, Martín Vega MÁ, Valero Domínguez M (July 2020). "Overview of treatments used in transthyretin-related hereditary amyloidosis: a systematic review". European Journal of Hospital Pharmacy. 27 (4): 194–201. doi:10.1136/ejhpharm-2018-001823. PMC 7335620. PMID 32587078.

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@@ Line 1: / Line 1: @@
 {{Short description|Metabolic disease involving abnormal deposited amyloid proteins}}
+{{cs1 config|name-list-style=vanc}}
 {{Use dmy dates|date=June 2022}}
-{{Infobox medical condition (new)
+{{Infobox medical condition
 | name          = Amyloidosis
-| image         = Amyloid fibril formation and classic facial features of AL amyloidosis.jpg
+| image         = Amyloidosis symptoms from Amyloidosis Support Groups.png
+| image_size    = 230px
-| caption       = Classic facial features of AL amyloidosis with [[purpura|bleeding under the skin]] (bruising) around the eyes<ref>{{cite web| vauthors = Hawkins P |title=AL amyloidosis|date=29 April 2015|url=http://wikilite.com/wikilite/index.php?title=AL_amyloidosis#28.1._Introduction|website=Wikilite.com|access-date=19 December 2015|url-status=live|archive-url=https://web.archive.org/web/20151222150708/http://wikilite.com/wikilite/index.php?title=AL_amyloidosis#28.1._Introduction|archive-date=22 December 2015}}</ref>
+| caption       = Amyloidosis symptoms are often vague and require different physician specialists for diagnosis.  Telltale symptoms may include an enlarged tongue ([[macroglossia]]) or bruising around the eyes ([[purpura]])<ref>{{cite web |title=Amyloidosis Awareness |url=https://www.amyloidosissupport.org/AmyloidAware_Booklet.pdf |website=amyloidaware.com |publisher=Amyloidosis Support Groups |date=1 March 2022 |access-date=15 June 2024 }}</ref>
-| field         = [[Hematology]], [[endocrinology]], [[rheumatology]], [[cardiology]]
+| field         = [[Internal medicine]]
 | symptoms      = Feeling tired, weight loss, swelling of the legs, shortness of breath, bleeding, feeling light headed with standing<ref name=Haz2013/>
 | complications =
 | onset         = 55–65 years old<ref name=Haz2013/>
 | duration      =
 | causes        = Genetic or acquired<ref name=Pep2006/>
 | risks         =
 | diagnosis     = [[Tissue biopsy]]<ref name=Haz2013/>
 | differential  =
 | prevention    =
 | treatment     = [[Supportive care]], directed at the underlying cause, [[Kidney dialysis|dialysis]], [[organ transplantation]]<ref name=Pep2006/>
 | medication    =
 | prognosis     = Improved with treatment<ref name=Pep2006/>
 | frequency     = 3–13 per million per year (AL amyloidosis)<ref name=Haz2013/>
 | deaths        = 1 per 1,000 people (developed world)<ref name=Pep2006/>
 }}
-<!-- Definition and symptoms -->
-'''Amyloidosis''' is a group of diseases in which abnormal [[protein]]s, known as [[amyloid fibrils]], build up in tissue.<ref>{{cite web|title=AL amyloidosis|url=https://rarediseases.info.nih.gov/diseases/5797/al-amyloidosis|website=rarediseases.info.nih.gov|publisher=Genetic and Rare Diseases Information Center (GARD)|access-date=22 April 2017|language=en|url-status=live|archive-url=https://web.archive.org/web/20170424001401/https://rarediseases.info.nih.gov/diseases/5797/al-amyloidosis|archive-date=24 April 2017}}</ref> There are several non-specific and vague signs and symptoms associated with amyloidosis.<ref name="Gertz_2020" /> These include fatigue, [[peripheral edema]], weight loss, shortness of breath, [[palpitations]], and [[Orthostatic hypotension|feeling faint with standing]].<ref name="Gertz_2020" /> In AL amyloidosis, specific indicators can include enlargement of the tongue and periorbital [[purpura]].<ref name="Gertz_2020" /> In wild-type ATTR amyloidosis, non-cardiac symptoms include: bilateral [[carpal tunnel syndrome]], lumbar [[spinal stenosis]], biceps tendon rupture, [[Small fiber peripheral neuropathy|small fiber neuropathy]], and [[autonomic dysfunction]].<ref name="Gertz_2020" />
+'''Amyloidosis''' is a group of diseases in which abnormal [[protein]]s, known as [[amyloid fibrils]], build up in tissue.<ref>{{cite web|title=AL amyloidosis|url=https://rarediseases.info.nih.gov/diseases/5797/al-amyloidosis|website=rarediseases.info.nih.gov|publisher=Genetic and Rare Diseases Information Center (GARD)|access-date=22 April 2017|language=en|url-status=live|archive-url=https://web.archive.org/web/20170424001401/https://rarediseases.info.nih.gov/diseases/5797/al-amyloidosis|archive-date=24 April 2017}}</ref> There are several non-specific and vague signs and symptoms associated with amyloidosis.<ref name="Gertz_2020" /> These include fatigue, [[peripheral edema]], [[weight loss]], [[shortness of breath]], [[palpitations]], and [[Orthostatic hypotension|feeling faint with standing]].<ref name="Gertz_2020" /> In AL amyloidosis, specific indicators can include enlargement of the tongue and periorbital [[purpura]].<ref name="Gertz_2020" /> In wild-type ATTR amyloidosis, non-cardiac symptoms include: bilateral [[carpal tunnel syndrome]], lumbar [[spinal stenosis]], [[biceps tendon rupture]], [[Small fiber peripheral neuropathy|small fiber neuropathy]], and [[autonomic dysfunction]].<ref name="Gertz_2020" />
-<!-- Types -->
-There are about 36 different types of amyloidosis, each due to a specific [[Proteopathy|protein misfolding]].<ref name="Picken_2020">{{cite journal | vauthors = Picken MM | title = The Pathology of Amyloidosis in Classification: A Review | language = english | journal = Acta Haematologica | volume = 143 | issue = 4 | pages = 322–334 | date = 2020 | pmid = 32392555 | doi = 10.1159/000506696 | s2cid = 218600304 }}</ref> Within these 36 proteins, 19 are grouped into [[Organ-limited amyloidosis|localized forms]], 14 are grouped as [[Systemic disease|systemic forms]], and 3 proteins can identify as either.<ref name="Picken_2020" /> These proteins can become irregular due to genetic effects, as well as through acquired [[environmental factor]]s.<ref name="Picken_2020" /> The four most common types of systemic amyloidosis are [[AL amyloidosis|light chain (AL)]], inflammation ([[AA amyloidosis|AA]]), [[Haemodialysis-associated amyloidosis|dialysis-related]] (Aβ<sub>2</sub>M), and hereditary and old age ([[Familial amyloid polyneuropathy|ATTR]] and [[Wild-type transthyretin amyloid]]<ref name=Ando2020>{{cite journal | vauthors = Ando Y, Coelho T, Berk JL, Cruz MW, Ericzon BG, Ikeda S, Lewis WD, Obici L, Planté-Bordeneuve V, Rapezzi C, Said G, Salvi F | display-authors = 6 | title = Guideline of transthyretin-related hereditary amyloidosis for clinicians | journal = Orphanet Journal of Rare Diseases | volume = 8 | pages = 31 | date = February 2013 | pmid = 23425518 | pmc = 3584981 | doi = 10.1186/1750-1172-8-31 | doi-access = free }}</ref>).<ref name="Haz2013">{{cite journal | vauthors = Hazenberg BP | title = Amyloidosis: a clinical overview | journal = Rheumatic Disease Clinics of North America | volume = 39 | issue = 2 | pages = 323–345 | date = May 2013 | pmid = 23597967 | doi = 10.1016/j.rdc.2013.02.012 | s2cid = 215069282 | url = https://research.rug.nl/en/publications/amyloidosis(f8ffcbe6-178d-4c7e-9cc2-c77053bbb0a6).html | access-date = 1 December 2021 | archive-date = 14 June 2022 | archive-url = https://web.archive.org/web/20220614060318/https://research.rug.nl/en/publications/amyloidosis-a-clinical-overview | url-status = live }}</ref>
+There are about 36 different types of amyloidosis, each due to a specific [[Proteopathy|protein misfolding]].<ref name="Picken_2020">{{cite journal | vauthors = Picken MM | title = The Pathology of Amyloidosis in Classification: A Review | language = english | journal = Acta Haematologica | volume = 143 | issue = 4 | pages = 322–334 | date = 2020 | pmid = 32392555 | doi = 10.1159/000506696 | s2cid = 218600304 | doi-access = free }}</ref> Within these 36 proteins, 19 are grouped into [[Organ-limited amyloidosis|localized forms]], 14 are grouped as [[Systemic disease|systemic forms]], and three proteins can identify as either.<ref name="Picken_2020" /> These proteins can become irregular due to genetic effects, as well as through acquired [[environmental factor]]s.<ref name="Picken_2020" /> The four most common types of systemic amyloidosis are [[AL amyloidosis|light chain (AL)]], inflammation ([[AA amyloidosis|AA]]), [[Haemodialysis-associated amyloidosis|dialysis-related]] (Aβ<sub>2</sub>M), and hereditary and old age ([[Familial amyloid polyneuropathy|ATTR]] and [[wild-type transthyretin amyloid]]<ref name=Ando2020>{{cite journal | vauthors = Ando Y, Coelho T, Berk JL, Cruz MW, Ericzon BG, Ikeda S, Lewis WD, Obici L, Planté-Bordeneuve V, Rapezzi C, Said G, Salvi F | display-authors = 6 | title = Guideline of transthyretin-related hereditary amyloidosis for clinicians | journal = Orphanet Journal of Rare Diseases | volume = 8 | pages = 31 | date = February 2013 | pmid = 23425518 | pmc = 3584981 | doi = 10.1186/1750-1172-8-31 | doi-access = free }}</ref>).<ref name="Haz2013">{{cite journal | vauthors = Hazenberg BP | title = Amyloidosis: a clinical overview | journal = Rheumatic Disease Clinics of North America | volume = 39 | issue = 2 | pages = 323–345 | date = May 2013 | pmid = 23597967 | doi = 10.1016/j.rdc.2013.02.012 | s2cid = 215069282 | url = https://research.rug.nl/files/17452552/Amyloidosis_Clinics_NA_2013.pdf }}</ref>
-<!-- Diagnosis -->
 Diagnosis may be suspected when [[proteinuria|protein is found in the urine]], [[organomegaly|organ enlargement]] is present, or [[polyneuropathy|problems are found with multiple peripheral nerves]] and it is unclear why.<ref name=Haz2013/> Diagnosis is confirmed by [[tissue biopsy]].<ref name=Haz2013/> Due to the variable presentation, a diagnosis can often take some time to reach.<ref name="Pep2006">{{cite journal | vauthors = Pepys MB | title = Amyloidosis | journal = Annual Review of Medicine | volume = 57 | pages = 223–241 | date = 2006 | pmid = 16409147 | doi = 10.1146/annurev.med.57.121304.131243 }}</ref>
+Treatment is geared towards decreasing the amount of the involved protein.<ref name=Haz2013/> This may sometimes be achieved by determining and treating the underlying cause.<ref name=Haz2013/> AL amyloidosis occurs in about 3–13 per million people per year and AA amyloidosis in about two per million people per year.<ref name=Haz2013/> The usual age of onset of these two types is 55 to 60 years old.<ref name=Haz2013/> Without treatment, life expectancy is between six months and four years.<ref name=Haz2013/> In the [[developed world]] about one per 1,000 deaths are from systemic amyloidosis.<ref name=Pep2006/> Amyloidosis has been described since at least 1639.<ref name=Haz2013/>
-<!-- Treatment, prognosis, epidemiology, and history -->
-Treatment is geared towards decreasing the amount of the involved protein.<ref name=Haz2013/> This may sometimes be achieved by determining and treating the underlying cause.<ref name=Haz2013/> AL amyloidosis occurs in about 3–13 per million people per year and AA amyloidosis in about 2 per million people per year.<ref name=Haz2013/> The usual age of onset of these two types is 55 to 60 years old.<ref name=Haz2013/> Without treatment, life expectancy is between six months and four years.<ref name=Haz2013/> In the [[developed world]] about 1 per 1,000 people die annually from systemic amyloidosis.<ref name=Pep2006/> Amyloidosis has been described since at least 1639.<ref name=Haz2013/>
-{{TOC limit|3}}
 == Signs and symptoms ==
-[[File:Amyloidosis cutis dyschromica.png|thumb|left|upright=1.3|Skin features of amyloidosis cutis dyschromica. Hyperpigmented and hypopigmented macules on (A) lower legs, (B) back and waist, (C) waist. (D) Individual blisters on upper arm]]
+[[File:Amyloidosis cutis dyschromica.png|thumb|left|upright=1.3|Skin features of amyloidosis cutis dyschromica. Hyperpigmented and hypopigmented macules on (A) lower legs, (B) back and waist, (C) waist. (D) Individual blisters on upper arm.]]
 The presentation of amyloidosis is broad and depends on the site of amyloid accumulation. The kidney and heart are the most common organs involved.
 ===Kidneys===
-[[Amyloid]] deposition in the [[kidney]] often involve the [[glomerular capillaries]] and [[Mesangial cell|mesangial regions]], affecting the organ's ability to filter and excrete waste and retain [[plasma protein]].<ref name="niddk">{{cite web | publisher = U.S. Department of Health and Human Services. | title = Amyloidosis & Kidney Disease. | work = National Institute of Diabetes and Digestive and Kidney Diseases. | access-date = 19 November 2021 | url = https://www.niddk.nih.gov/health-information/kidney-disease/amyloidosis | archive-date = 19 November 2021 | archive-url = https://web.archive.org/web/20211119221959/https://www.niddk.nih.gov/health-information/kidney-disease/amyloidosis | url-status = live }}</ref> This can lead to high levels of protein in the urine ([[proteinuria]]) and [[nephrotic syndrome]].<ref name="niddk" /> Several types of amyloidosis, including the AL and AA types, are associated with [[nephrotic syndrome]].<ref name="Lewis_2018">{{cite book | vauthors = Lewis JB, Neilson EG | date = 2018 | chapter = Glomerular Diseases | veditors = Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J | title = Harrison's Principles of Internal Medicine | edition = 20 | publisher = McGraw Hill | chapter-url = https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192281295 | access-date = 29 November 2021 | archive-date = 29 November 2021 | archive-url = https://web.archive.org/web/20211129202923/https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192281295 | url-status = live }}</ref> Approximately 20% and 40-60% of people with AL and AA amyloidosis respectively progress to [[End stage kidney disease|end-stage kidney disease]] requiring [[Kidney dialysis|dialysis]].<ref name="Lewis_2018" />
+[[Amyloid]] deposition in the [[kidney]] often involve the [[glomerular capillaries]] and [[Mesangial cell|mesangial regions]], affecting the organ's ability to filter and excrete waste and retain [[plasma protein]].<ref name="niddk">{{cite web | publisher = U.S. Department of Health and Human Services. | title = Amyloidosis & Kidney Disease. | work = National Institute of Diabetes and Digestive and Kidney Diseases. | access-date = 19 November 2021 | url = https://www.niddk.nih.gov/health-information/kidney-disease/amyloidosis | archive-date = 19 November 2021 | archive-url = https://web.archive.org/web/20211119221959/https://www.niddk.nih.gov/health-information/kidney-disease/amyloidosis | url-status = live }}</ref> This can lead to high levels of protein in the urine ([[proteinuria]]) and [[nephrotic syndrome]].<ref name="niddk" /> Several types of amyloidosis, including the AL and AA types, are associated with [[nephrotic syndrome]].<ref name="Lewis_2018">{{cite book | vauthors = Lewis JB, Neilson EG | date = 2018 | chapter = Glomerular Diseases | veditors = Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J | title = Harrison's Principles of Internal Medicine | edition = 20 | publisher = McGraw Hill | chapter-url = https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192281295 | access-date = 29 November 2021 | archive-date = 29 November 2021 | archive-url = https://web.archive.org/web/20211129202923/https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192281295 | url-status = live }}</ref> Approximately 20% and 40–60% of people with AL and AA amyloidosis respectively progress to [[End stage kidney disease|end-stage kidney disease]] requiring [[Kidney dialysis|dialysis]].<ref name="Lewis_2018" />
 ===Heart===
 {{Main|Cardiac amyloidosis}}
-Amyloid deposition in the heart can cause both diastolic and systolic [[heart failure]]. [[Electrocardiogram|EKG]] changes may be present, showing low voltage and conduction abnormalities like [[atrioventricular block]] or [[sinus node]] dysfunction.{{Medical citation needed|date=November 2021}} On [[Echocardiogram|echocardiography]], the heart shows a restrictive filling pattern, with normal to mildly reduced systolic function.<ref name="Falk_1997">{{cite journal | vauthors = Falk RH, Comenzo RL, Skinner M | title = The systemic amyloidoses | journal = The New England Journal of Medicine | volume = 337 | issue = 13 | pages = 898–909 | date = September 1997 | pmid = 9302305 | doi = 10.1056/NEJM199709253371306 }}</ref> AA amyloidosis usually spares the heart.<ref name="Ebert_2008" /> Cardiac amyloidosis can present with symptoms of heart failure including shortness of breath, fatigue, and edema.<ref name="Kyriakou_2018">{{cite journal | vauthors = Kyriakou P, Mouselimis D, Tsarouchas A, Rigopoulos A, Bakogiannis C, Noutsias M, Vassilikos V | title = Diagnosis of cardiac amyloidosis: a systematic review on the role of imaging and biomarkers | journal = BMC Cardiovascular Disorders | volume = 18 | issue = 1 | pages = 221 | date = December 2018 | pmid = 30509186 | pmc = 6278059 | doi = 10.1186/s12872-018-0952-8 }}</ref> As cardiac amyloidosis progresses, the amyloid deposition can affect the heart's ability to pump and fill blood as well as its ability to maintain normal rhythm, which leads to worsening heart function and decline in people's quality of life.<ref name="Kyriakou_2018" />
+Amyloid deposition in the heart can cause both diastolic and systolic [[heart failure]]. [[Electrocardiogram|EKG]] changes may be present, showing low voltage and conduction abnormalities like [[atrioventricular block]] or [[sinus node]] dysfunction.{{Medical citation needed|date=November 2021}} On [[Echocardiogram|echocardiography]], the heart shows a restrictive filling pattern, with normal to mildly reduced systolic function.<ref name="Falk_1997">{{cite journal | vauthors = Falk RH, Comenzo RL, Skinner M | title = The systemic amyloidoses | journal = The New England Journal of Medicine | volume = 337 | issue = 13 | pages = 898–909 | date = September 1997 | pmid = 9302305 | doi = 10.1056/NEJM199709253371306 }}</ref> AA amyloidosis usually spares the heart.<ref name="Ebert_2008" /> Cardiac amyloidosis can present with symptoms of heart failure including shortness of breath, fatigue, and edema.<ref name="Kyriakou_2018">{{cite journal | vauthors = Kyriakou P, Mouselimis D, Tsarouchas A, Rigopoulos A, Bakogiannis C, Noutsias M, Vassilikos V | title = Diagnosis of cardiac amyloidosis: a systematic review on the role of imaging and biomarkers | journal = BMC Cardiovascular Disorders | volume = 18 | issue = 1 | pages = 221 | date = December 2018 | pmid = 30509186 | pmc = 6278059 | doi = 10.1186/s12872-018-0952-8 | doi-access = free }}</ref> As cardiac amyloidosis progresses, the amyloid deposition can affect the heart's ability to pump and fill blood as well as its ability to maintain normal rhythm, which leads to worsening heart function and decline in people's quality of life.<ref name="Kyriakou_2018" />
 ===Nervous system===
-People with amyloidosis do not get central nervous system involvement but can develop sensory and autonomic neuropathies.{{Medical citation needed|date=November 2021}} Sensory neuropathy develops in a symmetrical pattern and progresses in a distal to proximal manner. Autonomic neuropathy can present as [[orthostatic hypotension]] but may manifest more gradually with nonspecific gastrointestinal symptoms like constipation, nausea, or early satiety.<ref name="Falk_1997" />
+People with amyloidosis may have central nervous system involvement,<ref>Soprano DR, Herbert J, Soprano KJ, Schon EA, Goodman DS. Demonstration of transthyretin mRNA in the brain and other extrahepatic tissues in the rat. J Biol Chem 1985; 260 (21) 11793-11798</ref> along with peripheral involvement which causes sensory and autonomic neuropathies. Sensory neuropathy develops in a symmetrical pattern and progresses in a distal to proximal manner. Autonomic neuropathy can present as [[orthostatic hypotension]] but may manifest more gradually with nonspecific gastrointestinal symptoms like constipation, nausea, or early satiety.<ref name="Falk_1997" /> Amyloidosis of the central nervous system can have more severe and systemic presentations that may include life-threatening arrhythmias, cardiac failure, malnutrition, infection, or death.<ref name="Kaku_2019" />
-Neuropathic presentation can depend on the etiology of amyloidosis.<ref name="Kaku_2019">{{cite journal | vauthors = Kaku M, Berk JL | title = Neuropathy Associated with Systemic Amyloidosis | journal = Seminars in Neurology | volume = 39 | issue = 5 | pages = 578–588 | date = October 2019 | pmid = 31639841 | doi = 10.1055/s-0039-1688994 | s2cid = 204850185 }}</ref> People with amyloidosis may experience dysfunction in various organ systems depending on the location and extent of nervous system involvement.<ref name="niddk" /> For example, peripheral neuropathy can cause erectile dysfunction, incontinence and constipation, pupillary dysfunction, and sensory loss depending on the distribution of amyloidosis along different peripheral nerves.<ref name="Kaku_2019" /> Amyloidosis of the central nervous system can have more severe and systemic presentations that may include life-threatening arrhythmias, cardiac failure, malnutrition, infection, or death.<ref name="Kaku_2019" />
+Neuropathic presentation can depend on the etiology of amyloidosis.<ref name="Kaku_2019">{{cite journal | vauthors = Kaku M, Berk JL | title = Neuropathy Associated with Systemic Amyloidosis | journal = Seminars in Neurology | volume = 39 | issue = 5 | pages = 578–588 | date = October 2019 | pmid = 31639841 | doi = 10.1055/s-0039-1688994 | s2cid = 204850185 }}</ref> People with amyloidosis may experience dysfunction in various organ systems depending on the location and extent of nervous system involvement.<ref name="niddk" /> For example, peripheral neuropathy can cause erectile dysfunction, incontinence and constipation, pupillary dysfunction, and sensory loss depending on the distribution of amyloidosis along different peripheral nerves.<ref name="Kaku_2019" />
 ===Gastrointestinal and accessory organs===
-Accumulation of amyloid proteins in the gastrointestinal system may be caused by a wide range of amyloid disorders and have different presentations depending on the degree of organ involvement.<ref name="Rowe_2017">{{cite journal | vauthors = Rowe K, Pankow J, Nehme F, Salyers W | title = Gastrointestinal Amyloidosis: Review of the Literature | journal = Cureus | volume = 9 | issue = 5 | pages = e1228 | date = May 2017 | pmid = 28611935 | doi = 10.7759/cureus.1228 | pmc = 5464793 }}</ref> Potential symptoms include weight loss, diarrhea, abdominal pain, heartburn (gastrointestinal reflux), and GI bleeding.<ref name="Rowe_2017" /> Amyloidosis may also affect accessory digestive organs including the liver, and may present with jaundice, fatty stool, anorexia, fluid buildup in the abdomen, and spleen enlargement.<ref name="Rowe_2017" />
+Accumulation of amyloid proteins in the gastrointestinal system may be caused by a wide range of amyloid disorders and have different presentations depending on the degree of organ involvement.<ref name="Rowe_2017">{{cite journal | vauthors = Rowe K, Pankow J, Nehme F, Salyers W | title = Gastrointestinal Amyloidosis: Review of the Literature | journal = Cureus | volume = 9 | issue = 5 | pages = e1228 | date = May 2017 | pmid = 28611935 | doi = 10.7759/cureus.1228 | doi-access = free | pmc = 5464793 }}</ref> Potential symptoms include weight loss, diarrhea, abdominal pain, heartburn (gastrointestinal reflux), and GI bleeding.<ref name="Rowe_2017" /> Amyloidosis may also affect accessory digestive organs including the liver, and may present with jaundice, fatty stool, anorexia, fluid buildup in the abdomen, and spleen enlargement.<ref name="Rowe_2017" />
 Accumulation of amyloid proteins in the liver can lead to elevations in serum [[aminotransferase]]s and [[alkaline phosphatase]], two biomarkers of liver injury, which is seen in about one third of people.<ref name="Ebert_2008" /> [[Hepatomegaly|Liver enlargement]] is common. In contrast, [[Splenomegaly|spleen enlargement]] is rare, occurring in 5% of people.<ref name="Falk_1997" /> Splenic dysfunction, leading to the presence of [[Howell-Jolly bodies]] on blood smear, occurs in 24% of people with amyloidosis.<ref name="Falk_1997" /> [[Malabsorption]] is seen in 8.5% of [[AL amyloidosis]] and 2.4% of AA amyloidosis. One suggested mechanism for the observed malabsorption is that amyloid deposits in the tips of [[intestinal villi]] (fingerlike projections that increase the intestinal area available for absorption of food),  begin to erode the functionality of the villi, presenting a [[coeliac disease|sprue]]-like picture.<ref name="Ebert_2008" />
@@ Line 61: / Line 59: @@
 ===Musculoskeletal system===
-Amyloid proteins deposit most commonly inside the knee, followed by hands, wrists, elbow, hip, and ankle, causing joint pain.<ref name="Takahashi 2016">{{cite journal | vauthors = Takahashi N, Glockner J, Howe BM, Hartman RP, Kawashima A | title = Taxonomy and Imaging Manifestations of Systemic Amyloidosis | journal = Radiologic Clinics of North America | volume = 54 | issue = 3 | pages = 597–612 | date = May 2016 | pmid = 27153791 | doi = 10.1016/j.rcl.2015.12.012 }}</ref> In males with advanced age (>80 years), there is significant risk of wild-type transthyretin amyloid deposition in synovial tissue of knee joint, but predominantly in old age deposition of wild type transthyretin is seen in cardiac ventricles. ATTR deposits have been found in [[Ligamenta flava|ligamentum flavum]] of patients that underwent surgery for [[lumbar spinal stenosis]].<ref>{{Cite journal |last1=Eldhagen |first1=P. |last2=Berg |first2=S. |last3=Lund |first3=L. H. |last4=Sörensson |first4=P. |last5=Suhr |first5=O. B. |last6=Westermark |first6=P. |date=June 2021 |title=Transthyretin amyloid deposits in lumbar spinal stenosis and assessment of signs of systemic amyloidosis |journal=Journal of Internal Medicine |volume=289 |issue=6 |pages=895–905 |doi=10.1111/joim.13222 |issn=1365-2796 |pmc=8248398 |pmid=33274477 }}</ref>
+Amyloid proteins deposit most commonly inside the knee, followed by hands, wrists, elbow, hip, and ankle, causing joint pain.<ref name="Takahashi 2016">{{cite journal | vauthors = Takahashi N, Glockner J, Howe BM, Hartman RP, Kawashima A | title = Taxonomy and Imaging Manifestations of Systemic Amyloidosis | journal = Radiologic Clinics of North America | volume = 54 | issue = 3 | pages = 597–612 | date = May 2016 | pmid = 27153791 | doi = 10.1016/j.rcl.2015.12.012 }}</ref> In males with advanced age (>80 years), there is significant risk of wild-type transthyretin amyloid deposition in synovial tissue of knee joint, but predominantly in old age deposition of wild type transthyretin is seen in cardiac ventricles. ATTR deposits have been found in [[Ligamenta flava|ligamentum flavum]] of patients that underwent surgery for [[lumbar spinal stenosis]].<ref>{{cite journal |last1=Eldhagen |first1=P. |last2=Berg |first2=S. |last3=Lund |first3=L. H. |last4=Sörensson |first4=P. |last5=Suhr |first5=O. B. |last6=Westermark |first6=P. |date=June 2021 |title=Transthyretin amyloid deposits in lumbar spinal stenosis and assessment of signs of systemic amyloidosis |journal=Journal of Internal Medicine |volume=289 |issue=6 |pages=895–905 |doi=10.1111/joim.13222 |issn=1365-2796 |pmc=8248398 |pmid=33274477 }}</ref>
-In beta 2-microglobulin amyloidosis, males have high risk of getting [[carpal tunnel syndrome]].<ref name="Nguyen_2018">{{cite journal | vauthors = Nguyen TX, Naqvi A, Thompson TL, Wilson RH | title = Musculoskeletal Manifestations of Amyloidosis: A Focused Review | journal = Journal of Surgical Orthopaedic Advances | volume = 27 | issue = 1 | pages = 1–5 | date =Spring 2018 | pmid = 29762107 }}</ref> Aβ2MG amyloidosis (Hemodialysis associated amyloidosis) tends to deposit in synovial tissue, causing chronic [[synovitis|inflammation of the synovial tissue]] in knee, hip, shoulder and interphalangeal joints.<ref name="Nguyen_2018" /> Amyloid light chains deposition in shoulder joint causes enlarged shoulders, also known as "[[Shoulder pad sign|shoulder pad sign]]".<ref name="Nguyen_2018" /> Amyloid light chain depositions can also cause bilateral symmetric polyarthritis.<ref name="Nguyen_2018" />
+In beta 2-microglobulin amyloidosis, males have high risk of getting [[carpal tunnel syndrome]].<ref name="Nguyen_2018">{{cite journal | vauthors = Nguyen TX, Naqvi A, Thompson TL, Wilson RH | title = Musculoskeletal Manifestations of Amyloidosis: A Focused Review | journal = Journal of Surgical Orthopaedic Advances | volume = 27 | issue = 1 | pages = 1–5 | date =Spring 2018 | pmid = 29762107 }}</ref> Aβ2MG amyloidosis (Hemodialysis associated amyloidosis) tends to deposit in synovial tissue, causing chronic [[synovitis|inflammation of the synovial tissue]] in knee, hip, shoulder and interphalangeal joints.<ref name="Nguyen_2018" /> Amyloid light chains deposition in shoulder joint causes enlarged shoulders, also known as "[[shoulder pad sign]]".<ref name="Nguyen_2018" /> Amyloid light chain depositions can also cause bilateral symmetric polyarthritis.<ref name="Nguyen_2018" />
 The deposition of amyloid proteins in the bone marrow without causing [[plasma cell dyscrasias]] is called amyloidoma. It is commonly found in cervical, lumbar, and sacral vertebrae. Those affected may be presented with bone pain due to bone lysis, lumbar [[paraparesis]], and a variety of neurological symptoms. Vertebral fractures are also common.<ref name="Nguyen_2018"/>
@@ Line 75: / Line 73: @@
 ==Pathogenesis==
 {{main|Amyloid}}
-Amyloidoses can be considered [[protein misfolding]] diseases.<ref name="Chiti_2017" /><ref name="Merlini_2011">{{cite journal | vauthors = Merlini G, Seldin DC, Gertz MA | title = Amyloidosis: pathogenesis and new therapeutic options | journal = Journal of Clinical Oncology | volume = 29 | issue = 14 | pages = 1924–1933 | date = May 2011 | pmid = 21483018 | pmc = 3138545 | doi = 10.1200/JCO.2010.32.2271 }}</ref> The vast majority of proteins that have been found to form amyloid deposits are [[secreted protein]]s, so the misfolding and formation of amyloid occurs outside cells, in the [[extracellular]] space.<ref name="Chiti_2017">{{cite journal | vauthors = Chiti F, Dobson CM | title = Protein Misfolding, Amyloid Formation, and Human Disease: A Summary of Progress Over the Last Decade | journal = Annual Review of Biochemistry | volume = 86 | pages = 27–68 | date = June 2017 | pmid = 28498720 | doi = 10.1146/annurev-biochem-061516-045115 | hdl = 2158/1117236 }}</ref> Of the 37 proteins so far identified as being vulnerable to amyloid formation, only four are [[cytosol]]ic.<ref name="Chiti_2017" /> Most amyloid-forming proteins are relatively small, but otherwise there is currently no evidence of structural or functional similarities among proteins known to form disease-associated amyloids.<ref name="Chiti_2017" />  One third of amyloid disease is hereditary, in which case there is normally an early age of onset.<ref name="Chiti_2017" /> Half of amyloid-related diseases are sporadic and have a late age of onset – in these cases, the protein aggregation may be associated with aging-related decline in protein regulation. Rarely, some medical treatments are associated with amyloid disease.<ref name="Chiti_2017" />
+Amyloidoses can be considered [[protein misfolding]] diseases.<ref name="Chiti_2017" /><ref name="Merlini_2011">{{cite journal | vauthors = Merlini G, Seldin DC, Gertz MA | title = Amyloidosis: pathogenesis and new therapeutic options | journal = Journal of Clinical Oncology | volume = 29 | issue = 14 | pages = 1924–1933 | date = May 2011 | pmid = 21483018 | pmc = 3138545 | doi = 10.1200/JCO.2010.32.2271 }}</ref> The vast majority of proteins that have been found to form amyloid deposits are [[secreted protein]]s, so the misfolding and formation of amyloid occurs outside cells, in the [[extracellular]] space.<ref name="Chiti_2017">{{cite journal | vauthors = Chiti F, Dobson CM | title = Protein Misfolding, Amyloid Formation, and Human Disease: A Summary of Progress Over the Last Decade | journal = Annual Review of Biochemistry | volume = 86 | pages = 27–68 | date = June 2017 | pmid = 28498720 | doi = 10.1146/annurev-biochem-061516-045115 | hdl = 2158/1117236 | hdl-access = free }}</ref> Of the 37 proteins so far identified as being vulnerable to amyloid formation, only four are [[cytosol]]ic.<ref name="Chiti_2017" /> Most amyloid-forming proteins are relatively small, but otherwise there is currently no evidence of structural or functional similarities among proteins known to form disease-associated amyloids.<ref name="Chiti_2017" />  One third of amyloid disease is hereditary, in which case there is normally an early age of onset.<ref name="Chiti_2017" /> Half of amyloid-related diseases are sporadic and have a late age of onset – in these cases, the protein aggregation may be associated with aging-related decline in protein regulation. Some medical treatments are associated with amyloid disease, but this is rare.<ref name="Chiti_2017" />
-Amyloid-forming proteins aggregate into distinctive fibrillar forms with a [[beta-sheet]] structure.<ref name="Chiti_2017" /><ref name=Merlini_2011 /> The beta-sheet form of amyloid is [[proteolysis]]-resistant, meaning it can not be degraded or broken down.<ref name="Gertz_2020" /> As a result, amyloid deposits into the body's extracellular space.<ref name="Gertz_2020" /> The process of forming amyloid fibrils is thought to have intermediate [[oligomer]]ic forms. Both the oligomers and amyloid fibrils can be toxic to cells and can interfere with proper organ function.<ref>{{cite book | vauthors = Gertz MA, Rajkumar SV |title=Amyloidosis |date=2010 |publisher=Humana |location=Totowa, N.J. |isbn=978-1-60761-631-3}}</ref> The relative significance of different aggregation species may depend on the protein involved and the organ system affected.<ref name=Merlini_2011 />
+Amyloid-forming proteins aggregate into distinctive fibrillar forms with a [[beta-sheet]] structure.<ref name="Chiti_2017" /><ref name=Merlini_2011 /> The beta-sheet form of amyloid is [[proteolysis]]-resistant, meaning it can not be degraded or broken down.<ref name="Gertz_2020" /> As a result, amyloid deposits into the body's extracellular space.<ref name="Gertz_2020" /> The process of forming amyloid fibrils is thought to have intermediate [[oligomer]]ic forms. Both the oligomers and amyloid fibrils can be toxic to cells and can interfere with proper organ function.<ref>{{cite book | vauthors = Gertz MA, Rajkumar SV |title=Amyloidosis |date=2010 |publisher=Humana |location=Totowa, N.J. |isbn=978-1-60761-631-3 |oclc=654382006}}</ref> The relative significance of different aggregation species may depend on the protein involved and the organ system affected.<ref name=Merlini_2011 />
 ==Diagnosis==
-Diagnosis of amyloidosis generally requires tissue biopsy.<ref name="Haz2013" /> The biopsy is assessed for evidence of characteristic amyloid deposits. The tissue is treated with various [[Histology#Common laboratory stains|stains]]. The most useful stain in the diagnosis of amyloid is [[Congo red]], which, combined with [[Polarization (waves)|polarized light]], makes the amyloid proteins appear apple-green on [[microscopy]]. Also, [[Thioflavin|thioflavin T]] stain may be used.<ref name="Dember2006">{{cite journal | vauthors = Dember LM | title = Amyloidosis-associated kidney disease | journal = Journal of the American Society of Nephrology | volume = 17 | issue = 12 | pages = 3458–3471 | date = December 2006 | pmid = 17093068 | doi = 10.1681/ASN.2006050460 | url = http://jasn.asnjournals.org/content/17/12/3458.long | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20111205032749/http://jasn.asnjournals.org/content/17/12/3458.long | archive-date = 5 December 2011 }}</ref> A number of imaging techniques such as a [[DPD scan]] or [[SAP scan]] are also in use.<ref>{{cite journal | vauthors = Sachchithanantham S, Wechalekar AD | title = Imaging in systemic amyloidosis | journal = British Medical Bulletin | volume = 107 | pages = 41–56 | date = 2013 | pmid = 23896486 | doi = 10.1093/bmb/ldt021 | doi-access = free }}</ref>
+Diagnosis of amyloidosis generally requires tissue biopsy.<ref name="Haz2013" /> The biopsy is assessed for evidence of characteristic amyloid deposits. The tissue is treated with various [[Histology#Common laboratory stains|stains]]. The most useful stain in the diagnosis of amyloid is [[Congo red]], which, combined with [[Polarization (waves)|polarized light]], makes the amyloid proteins appear apple-green on [[microscopy]]. Also, [[Thioflavin|thioflavin T]] stain may be used.<ref name="Dember2006">{{cite journal | vauthors = Dember LM | title = Amyloidosis-associated kidney disease | journal = Journal of the American Society of Nephrology | volume = 17 | issue = 12 | pages = 3458–3471 | date = December 2006 | pmid = 17093068 | doi = 10.1681/ASN.2006050460 | url = http://jasn.asnjournals.org/content/17/12/3458.long | url-status = live | doi-access = free | archive-url = https://web.archive.org/web/20111205032749/http://jasn.asnjournals.org/content/17/12/3458.long | archive-date = 5 December 2011 }}</ref> A number of imaging techniques such as a Nuclear Medicine PYP scan, [[DPD scan]] or [[SAP scan]] are also in use.<ref>{{cite journal | vauthors = Sachchithanantham S, Wechalekar AD | title = Imaging in systemic amyloidosis | journal = British Medical Bulletin | volume = 107 | pages = 41–56 | date = 2013 | pmid = 23896486 | doi = 10.1093/bmb/ldt021 | doi-access = free }}</ref>
 A sample of tissue can be biopsied or obtained directly from the affected internal organ, but the first-line site of biopsy is [[Subcutaneous tissue#Subcutaneous fat|subcutaneous abdominal fat]], known as a "fat pad biopsy", due to its ease of acquisition.<ref name="Merlini_2018">{{cite journal | vauthors = Merlini G, Dispenzieri A, Sanchorawala V, Schönland SO, Palladini G, Hawkins PN, Gertz MA | title = Systemic immunoglobulin light chain amyloidosis | journal = Nature Reviews. Disease Primers | volume = 4 | issue = 1 | pages = 38 | date = October 2018 | pmid = 30361521 | doi = 10.1038/s41572-018-0034-3 | s2cid = 53023121 | url = https://discovery.ucl.ac.uk/id/eprint/10065475/ | access-date = 25 December 2020 | archive-date = 14 June 2022 | archive-url = https://web.archive.org/web/20220614060316/https://discovery.ucl.ac.uk/id/eprint/10065475/ | url-status = live }}</ref><ref name="Wechalekar_2016">{{cite journal | vauthors = Wechalekar AD, Gillmore JD, Hawkins PN | title = Systemic amyloidosis | journal = Lancet | volume = 387 | issue = 10038 | pages = 2641–2654 | date = June 2016 | pmid = 26719234 | doi = 10.1016/S0140-6736(15)01274-X | s2cid = 4762107 }}</ref> An abdominal fat biopsy is not completely [[Sensitivity and specificity|sensitive]] and may result in [[False positives and false negatives|false negatives]], which means a negative result does not exclude the diagnosis of amyloidosis.<ref name="Merlini_2018" /><ref name="Wechalekar_2016" /> However, direct biopsy of the affected organ may still be unnecessary as other less invasive methods of biopsy can also be used, including rectal mucosa, salivary gland, lip, or bone marrow biopsy which can achieve a diagnosis in up to 85% of people.<ref name="Merlini_2018" />
@@ Line 86: / Line 84: @@
 In the amyloid deposition of the joints, there will be a decreased signal in both [[MRI sequence#T1 and T2|T1 and T2 weighted MRI images]].<ref name="Takahashi 2016"/> In amyloidoma, there will be low T1 signal with gadolinium injection and low T2 signal.<ref name="Nguyen_2018"/>
-The type of the amyloid protein can be determined in various ways: the detection of abnormal proteins in the bloodstream (on [[protein electrophoresis]] or light chain determination); binding of particular antibodies to the amyloid found in the tissue (immunohistochemistry); or extraction of the protein and identification of its individual [[amino acid]]s.<ref name=Dember2006/> Immunohistochemistry can identify AA amyloidosis the majority of the time, but can miss many cases of AL amyloidosis.<ref name="Ebert_2008" /> [[Laser capture microdissection|Laser microdissection]] with [[mass spectrometry]] is the most reliable method of identifying the different forms of amyloidosis.<ref name="Rosenzweig_2011">{{cite journal | vauthors = Rosenzweig M, Landau H | title = Light chain (AL) amyloidosis: update on diagnosis and management | journal = Journal of Hematology & Oncology | volume = 4 | issue = 1 | pages = 47 | date = November 2011 | pmid = 22100031 | pmc = 3228694 | doi = 10.1186/1756-8722-4-47 }}</ref>
+The type of the amyloid protein can be determined in various ways: the detection of abnormal proteins in the bloodstream (on [[protein electrophoresis]] or light chain determination); binding of particular antibodies to the amyloid found in the tissue (immunohistochemistry); or extraction of the protein and identification of its individual [[amino acid]]s.<ref name=Dember2006/> Immunohistochemistry can identify AA amyloidosis the majority of the time, but can miss many cases of AL amyloidosis.<ref name="Ebert_2008" /> [[Laser capture microdissection|Laser microdissection]] with [[mass spectrometry]] is the most reliable method of identifying the different forms of amyloidosis.<ref name="Rosenzweig_2011">{{cite journal | vauthors = Rosenzweig M, Landau H | title = Light chain (AL) amyloidosis: update on diagnosis and management | journal = Journal of Hematology & Oncology | volume = 4 | issue = 1 | pages = 47 | date = November 2011 | pmid = 22100031 | pmc = 3228694 | doi = 10.1186/1756-8722-4-47 | doi-access = free }}</ref>
 AL was previously considered the most common form of amyloidosis, and a diagnosis often begins with a search for [[plasma cell dyscrasia]], memory B cells producing aberrant immunoglobulins or portions of immunoglobulins. Immunofixation electrophoresis of urine or serum is positive in 90% of people with AL amyloidosis.<ref name="Falk_1997" /> Immunofixation electrophoresis is more sensitive than regular electrophoresis but may not be available in all centers. Alternatively immunohistochemical staining of a bone marrow biopsy looking for dominant plasma cells can be sought in people with a high clinical suspicion for AL amyloidosis but negative electrophoresis.<ref name="Falk_1997" />
-ATTR is now considered to be the most common form of amyloidosis, and no longer considered as a rare disease.<ref>{{cite journal |last1=Kazi |first1=DS |title=Cost-Effectiveness of Tafamidis Therapy for Transthyretin Amyloid Cardiomyopathy. Circulation |journal=Circulation |date=2020 |volume=141 |issue=15 |pages=1214–1224 |doi=10.1161/CIRCULATIONAHA.119.045093|pmid=32078382 |pmc=7156331 }}</ref> It may be either age related in wild-type ATTR (ATTRv) or familial transthyretin-associated amyloidosis, is suspected in people with family history of idiopathic neuropathies or heart failure who lack evidence of plasma cell dyscrasias. ATTR can be identified using [[isoelectric focusing]] which separates mutated forms of transthyretin. Findings can be corroborated by genetic testing to look for specific known mutations in transthyretin that predispose to amyloidosis.<ref name="Falk_1997" />
+ATTR is now considered to be the most common form of amyloidosis. It may be either age related in wild-type ATTR (ATTRv) or familial transthyretin-associated amyloidosis, is suspected in people with family history of idiopathic neuropathies or heart failure who lack evidence of plasma cell dyscrasias. ATTR can be identified using [[isoelectric focusing]] which separates mutated forms of transthyretin. Findings can be corroborated by [[genetic testing]] to look for specific known mutations in transthyretin that predispose to amyloidosis.<ref name="Falk_1997" />
 AA is suspected on clinical grounds in individuals with longstanding infections or inflammatory diseases. AA can be identified by immunohistochemistry staining.<ref name="Falk_1997" />
@@ Line 107: / Line 105: @@
 === Classification ===
-Historical classification systems were based on clinical factors. Until the early 1970s, the idea of a single amyloid substance predominated. Various descriptive classification systems were proposed based on the organ distribution of amyloid deposits and clinical findings. Most classification systems included primary (i.e., [[idiopathic]]) amyloidosis, in which no associated clinical condition was identified, and secondary amyloidosis (i.e., [[wikt:secondary|secondary]] to chronic inflammatory conditions). Some classification systems included myeloma-associated, familial, and localized amyloidosis.
+Historical classification systems were based on clinical factors. Until the early 1970s, the idea of a single amyloid substance predominated. Various descriptive classification systems were proposed based on the organ distribution of amyloid deposits and clinical findings. Most classification systems included primary (i.e., [[idiopathic]]) amyloidosis, in which no associated clinical condition was identified, and secondary amyloidosis (i.e., [[wikt:secondary|secondary]] to chronic inflammatory conditions). Some classification systems included myeloma-associated, familial, and localized amyloidosis.{{citation needed|date=January 2024}}
 The modern era of amyloidosis classification began in the late 1960s with the development of methods to make amyloid fibrils soluble. These methods permitted scientists to study the chemical properties of amyloids.{{Medical citation needed|date=November 2021}} Descriptive terms such as primary amyloidosis, secondary amyloidosis, and others (e.g., senile amyloidosis), which are not based on cause, provide little useful information and are no longer recommended.
@@ Line 117: / Line 115: @@
 About 60 amyloid proteins have been identified so far.<ref name="pmid17223074">{{cite journal | vauthors = Mok KH, Pettersson J, Orrenius S, Svanborg C | title = HAMLET, protein folding, and tumor cell death | journal = Biochemical and Biophysical Research Communications | volume = 354 | issue = 1 | pages = 1–7 | date = March 2007 | pmid = 17223074 | doi = 10.1016/j.bbrc.2006.12.167 }}</ref> Of those, at least 36 have been associated with a human disease.<ref name="pmid18985467">{{cite journal | vauthors = Pettersson-Kastberg J, Aits S, Gustafsson L, Mossberg A, Storm P, Trulsson M, Persson F, Mok KH, Svanborg C | display-authors = 6 | title = Can misfolded proteins be beneficial? The HAMLET case | journal = Annals of Medicine | volume = 41 | issue = 3 | pages = 162–176 | date = November 2008 | pmid = 18985467 | doi = 10.1080/07853890802502614 | s2cid = 31198109 }}</ref>
-All amyloid fibril proteins start with the letter "A" followed by the protein suffix (and any applicable specification). See below for a list of amyloid fibril proteins which have been found in humans:<ref>{{cite journal | vauthors = Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJ, Sekijima Y, Sipe JD, Westermark P | display-authors = 6 | title = Amyloid nomenclature 2020: update and recommendations by the International Society of Amyloidosis (ISA) nomenclature committee | journal = Amyloid | volume = 27 | issue = 4 | pages = 217–222 | date = December 2020 | pmid = 33100054 | doi = 10.1080/13506129.2020.1835263 | s2cid = 225073269 }}</ref>
+All amyloid fibril proteins start with the letter "A" followed by the protein suffix (and any applicable specification). See below for a list of amyloid fibril proteins which have been found in humans:<ref>{{cite journal | vauthors = Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJ, Sekijima Y, Sipe JD, Westermark P | display-authors = 6 | title = Amyloid nomenclature 2020: update and recommendations by the International Society of Amyloidosis (ISA) nomenclature committee | journal = Amyloid | volume = 27 | issue = 4 | pages = 217–222 | date = December 2020 | pmid = 33100054 | doi = 10.1080/13506129.2020.1835263 | s2cid = 225073269 | doi-access = free }}</ref>
 {| class="wikitable sortable"
 !Fibril protein
@@ Line 383: / Line 381: @@
 |-
 |AEFEMP1<sup>e</sup>
 |EGF-containing fibulin-like extracellular
 matrix protein 1 (EFEMP1)
 |Portal veins, Aging associated
@@ Line 404: / Line 402: @@
 Treatment depends on the type of amyloidosis that is present. Treatment with high dose [[melphalan]], a [[chemotherapy]] agent, followed by [[stem cell]] transplantation has shown promise in early studies and is recommended for stage I and II AL amyloidosis.<ref name="Rosenzweig_2011" /> However, only 20–25% of people are eligible for stem cell transplant. Chemotherapy treatment including cyclophosphamide-bortezomib-dexamethasone is currently the recommended treatment option for people with AL Amyloidosis not eligible for transplant.<ref name="Gertz_2020" />
-In AA, symptoms may improve if the underlying condition is treated. In people who have inflammation caused by AA amyloidosis, [[TNF inhibitor|tumour necrosis factor (TNF)-alpha inhibitors]] such as [[infliximab]] and [[etanercept]] are used for an average duration of 20 months. If TNF-alpha inhibitors are not effective, [[Interleukin-1 family|Interleukin-1]] inhibitors (e.g. [[anakinra]], [[canakinumab]], [[rilonacept]]) and [[Interleukin 6|interleukin-6]] inhibitors (e.g. tocilizumab) may be considered.<ref>{{cite journal | vauthors = ter Haar NM, Oswald M, Jeyaratnam J, Anton J, Barron KS, Brogan PA, Cantarini L, Galeotti C, Grateau G, Hentgen V, Hofer M, Kallinich T, Kone-Paut I, Lachmann HJ, Ozdogan H, Ozen S, Russo R, Simon A, Uziel Y, Wouters C, Feldman BM, Vastert SJ, Wulffraat NM, Benseler SM, Frenkel J, Gattorno M, Kuemmerle-Deschner JB | display-authors = 6 | title = Recommendations for the management of autoinflammatory diseases | journal = Annals of the Rheumatic Diseases | volume = 74 | issue = 9 | pages = 1636–1644 | date = September 2015 | pmid = 26109736 | doi = 10.1136/annrheumdis-2015-207546 | hdl = 2445/108897 | s2cid = 18876892 }}</ref>
+In AA, symptoms may improve if the underlying condition is treated. In people who have inflammation caused by AA amyloidosis, [[TNF inhibitor|tumour necrosis factor (TNF)-alpha inhibitors]] such as [[infliximab]] and [[etanercept]] are used for an average duration of 20 months. If TNF-alpha inhibitors are not effective, [[Interleukin-1 family|Interleukin-1]] inhibitors (e.g., [[anakinra]], [[canakinumab]], [[rilonacept]]) and [[Interleukin 6|interleukin-6]] inhibitors (e.g., tocilizumab) may be considered.<ref>{{cite journal | vauthors = ter Haar NM, Oswald M, Jeyaratnam J, Anton J, Barron KS, Brogan PA, Cantarini L, Galeotti C, Grateau G, Hentgen V, Hofer M, Kallinich T, Kone-Paut I, Lachmann HJ, Ozdogan H, Ozen S, Russo R, Simon A, Uziel Y, Wouters C, Feldman BM, Vastert SJ, Wulffraat NM, Benseler SM, Frenkel J, Gattorno M, Kuemmerle-Deschner JB | display-authors = 6 | title = Recommendations for the management of autoinflammatory diseases | journal = Annals of the Rheumatic Diseases | volume = 74 | issue = 9 | pages = 1636–1644 | date = September 2015 | pmid = 26109736 | doi = 10.1136/annrheumdis-2015-207546 | hdl = 2445/108897 | s2cid = 18876892 | hdl-access = free }}</ref>
-Management of ATTR amyloidosis will depend on its classification as wild type or variant.<ref name="Gertz_2020">{{cite journal | vauthors = Gertz MA, Dispenzieri A | title = Systemic Amyloidosis Recognition, Prognosis, and Therapy: A Systematic Review | journal = JAMA | volume = 324 | issue = 1 | pages = 79–89 | date = July 2020 | pmid = 32633805 | doi = 10.1001/jama.2020.5493 | s2cid = 220385853 }}</ref> Both may be treated with [[tafamidis]], a low toxicity oral agent that prevents destabilization of correctly folded protein.<ref name="Gertz_2020" /> Studies showed [[tafamidis]] reduced mortality and hospitalization due to [[heart failure]].<ref name="Gertz_2020" /> Previously, for variant ATTR amyloidosis, [[Liver transplantation|liver transplant]] was the only effective treatment.<ref name="Gertz_2020" /> New therapies include [[diflunisal]], [[inotersen]], and [[patisiran]].
+Management of ATTR amyloidosis will depend on its classification as wild type or variant.<ref name="Gertz_2020">{{cite journal | vauthors = Gertz MA, Dispenzieri A | title = Systemic Amyloidosis Recognition, Prognosis, and Therapy: A Systematic Review | journal = JAMA | volume = 324 | issue = 1 | pages = 79–89 | date = July 2020 | pmid = 32633805 | doi = 10.1001/jama.2020.5493 | s2cid = 220385853 }}</ref> Both may be treated with [[tafamidis]], a low toxicity oral agent that prevents destabilization of correctly folded protein.<ref name="Gertz_2020" /> Studies showed tafamidis reduced mortality and hospitalization due to [[heart failure]].<ref name="Gertz_2020" /> Previously, for variant ATTR amyloidosis, [[Liver transplantation|liver transplant]] was the only effective treatment.<ref name="Gertz_2020" /> New therapies include [[diflunisal]], [[inotersen]], and [[patisiran]].
 Diflunisal binds to misfolded mutant TTR protein to prevent its buildup, like how tafamidis works. Low-certainty evidence indicates that it mitigates worsening of [[peripheral neuropathy]] and disability from disease progression.<ref name="Magrinelli_2020">{{cite journal | vauthors = Magrinelli F, Fabrizi GM, Santoro L, Manganelli F, Zanette G, Cavallaro T, Tamburin S | title = Pharmacological treatment for familial amyloid polyneuropathy | journal = The Cochrane Database of Systematic Reviews | volume = 4 | pages = CD012395 | date = April 2020 | issue = 4 | pmid = 32311072 | pmc = 7170468 | doi = 10.1002/14651858.CD012395.pub2 | collaboration = Cochrane Neuromuscular Group }}</ref>
-Inotersen blocks gene expression of both wild-type and mutant TTR, reducing amyloid precursor. Moderate-certainty evidence suggests that it mitigates worsening of peripheral neuropathy. Long-term efficacy and safety of inotersen use in people with mutant TTR-related amyloidosis is still be evaluated in a phase-III clinical trial as of 2021. Both diflunisal and inotersen may also mitigate declines in quality-of-life, though the evidence for this effect is unclear.<ref name="Magrinelli_2020" /> For people with cardiac ATTR the effect of inotersen use is inconclusive and requires further investigation.<ref name="Marques_2020">{{cite journal | vauthors = Marques N, Azevedo O, Almeida AR, Bento D, Cruz I, Correia E, Lourenço C, Lopes LR | display-authors = 6 | title = Specific Therapy for Transthyretin Cardiac Amyloidosis: A Systematic Literature Review and Evidence-Based Recommendations | journal = Journal of the American Heart Association | volume = 9 | issue = 19 | pages = e016614 | date = October 2020 | pmid = 32969287 | pmc = 7792401 | doi = 10.1161/JAHA.120.016614 }}</ref> In 2018, [[inotersen]] was approved by the European Medicines Agency to treat polyneuropathy in adults with hereditary transthyretin amyloidosis.<ref>{{cite web | title = Tegsedi | work = Europeans Medicines Agency | url = https://www.ema.europa.eu/en/medicines/human/EPAR/tegsedi | access-date = 12 March 2021 | archive-date = 8 October 2020 | archive-url = https://web.archive.org/web/20201008061412/https://www.ema.europa.eu/en/medicines/human/EPAR/tegsedi | url-status = live }}</ref> It has since been approved for use in Canada, the European Union and in the USA.<ref>{{cite journal | vauthors = Mathew V, Wang AK | title = Inotersen: new promise for the treatment of hereditary transthyretin amyloidosis | language = English | journal = Drug Design, Development and Therapy | volume = 13 | pages = 1515–1525 | date = 6 May 2019 | pmid = 31118583 | pmc = 6507904 | doi = 10.2147/DDDT.S162913 }}</ref>
+Inotersen blocks gene expression of both wild-type and mutant TTR, reducing amyloid precursor. Moderate-certainty evidence suggests that it mitigates worsening of peripheral neuropathy. Long-term efficacy and safety of inotersen use in people with mutant TTR-related amyloidosis is still be evaluated in a phase-III clinical trial as of 2021. Both diflunisal and inotersen may also mitigate declines in quality-of-life, though the evidence for this effect is unclear.<ref name="Magrinelli_2020" /> For people with cardiac ATTR the effect of inotersen use is inconclusive and requires further investigation.<ref name="Marques_2020">{{cite journal | vauthors = Marques N, Azevedo O, Almeida AR, Bento D, Cruz I, Correia E, Lourenço C, Lopes LR | display-authors = 6 | title = Specific Therapy for Transthyretin Cardiac Amyloidosis: A Systematic Literature Review and Evidence-Based Recommendations | journal = Journal of the American Heart Association | volume = 9 | issue = 19 | pages = e016614 | date = October 2020 | pmid = 32969287 | pmc = 7792401 | doi = 10.1161/JAHA.120.016614 }}</ref> In 2018, [[inotersen]] was approved by the European Medicines Agency to treat polyneuropathy in adults with hereditary transthyretin amyloidosis.<ref>{{cite web | title = Tegsedi | work = Europeans Medicines Agency | url = https://www.ema.europa.eu/en/medicines/human/EPAR/tegsedi | access-date = 12 March 2021 | archive-date = 8 October 2020 | archive-url = https://web.archive.org/web/20201008061412/https://www.ema.europa.eu/en/medicines/human/EPAR/tegsedi | url-status = live }}</ref> It has since been approved for use in Canada, the European Union and in the USA.<ref>{{cite journal | vauthors = Mathew V, Wang AK | title = Inotersen: new promise for the treatment of hereditary transthyretin amyloidosis | language = English | journal = Drug Design, Development and Therapy | volume = 13 | pages = 1515–1525 | date = 6 May 2019 | pmid = 31118583 | pmc = 6507904 | doi = 10.2147/DDDT.S162913 | doi-access = free }}</ref>
-[[Patisiran]] functions similarly to inotersen. Moderate-certainty evidence suggests that patisiran mitigates worsening of peripheral neuropathy and disability from disease progression. Additionally, low-certainty evidence suggests that patisiran mitigates decreases in quality-of-life and slightly reduces the rate of adverse events versus placebo. There is no evidence of an effect on mortality rate.<ref name="Magrinelli_2020" /> A review of early data from use of patisiran in people with variant cardiac ATTR suggests that it may reduce mortality and hospitalization, however this is still being investigated and requires further investigation.<ref name="Marques_2020" /> In 2018, [[patisiran]] was not recommended by NICE in the UK for hereditary transthyretin-related amyloidosis.<ref>{{cite web|title=Patisiran for treating hereditary transthyretinrelated amyloidosis|url=https://www.nice.org.uk/guidance/gid-hst10014/documents/evaluation-consultation-document|access-date=20 July 2019|archive-date=4 July 2019|archive-url=https://web.archive.org/web/20190704103207/https://www.nice.org.uk/guidance/gid-hst10014/documents/evaluation-consultation-document|url-status=live}}</ref> As of July 2019 further review however is occurring.<ref>{{cite web|title=Patisiran for treating hereditary transthyretin-related amyloidosis [ID1279] {{!}} Guidance {{!}} NICE|url=https://www.nice.org.uk/guidance/indevelopment/gid-hst10014|access-date=20 July 2019|work=National Institute for Health and Care Excellence (Nice)|archive-date=20 July 2019|archive-url=https://web.archive.org/web/20190720003858/https://www.nice.org.uk/guidance/indevelopment/gid-hst10014|url-status=live}}</ref> It was approved for this use in the United States, however.<ref>{{cite journal | vauthors = Hoy SM | title = Patisiran: First Global Approval | journal = Drugs | volume = 78 | issue = 15 | pages = 1625–1631 | date = October 2018 | pmid = 30251172 | doi = 10.1007/s40265-018-0983-6 | s2cid = 52813638 }}</ref>
+[[Patisiran]] functions similarly to inotersen. Moderate-certainty evidence suggests that patisiran mitigates worsening of peripheral neuropathy and disability from disease progression. Additionally, low-certainty evidence suggests that patisiran mitigates decreases in quality-of-life and slightly reduces the rate of adverse events versus placebo. There is no evidence of an effect on mortality rate.<ref name="Magrinelli_2020" /> A review of early data from use of patisiran in people with variant cardiac ATTR suggests that it may reduce mortality and hospitalization, however this is still being investigated and requires further investigation.<ref name="Marques_2020" /> In 2018, patisiran was not recommended by NICE in the UK for hereditary transthyretin-related amyloidosis.<ref>{{cite web|title=Patisiran for treating hereditary transthyretinrelated amyloidosis|url=https://www.nice.org.uk/guidance/gid-hst10014/documents/evaluation-consultation-document|access-date=20 July 2019|archive-date=4 July 2019|archive-url=https://web.archive.org/web/20190704103207/https://www.nice.org.uk/guidance/gid-hst10014/documents/evaluation-consultation-document|url-status=live}}</ref> As of July 2019 further review however is occurring.<ref>{{cite web|title=Patisiran for treating hereditary transthyretin-related amyloidosis [ID1279] {{!}} Guidance {{!}} NICE|url=https://www.nice.org.uk/guidance/indevelopment/gid-hst10014|access-date=20 July 2019|work=National Institute for Health and Care Excellence (Nice)|archive-date=20 July 2019|archive-url=https://web.archive.org/web/20190720003858/https://www.nice.org.uk/guidance/indevelopment/gid-hst10014|url-status=live}}</ref> It was approved for this use in the United States, however.<ref>{{cite journal | vauthors = Hoy SM | title = Patisiran: First Global Approval | journal = Drugs | volume = 78 | issue = 15 | pages = 1625–1631 | date = October 2018 | pmid = 30251172 | doi = 10.1007/s40265-018-0983-6 | s2cid = 52813638 }}</ref>
 The roles of inotersen and patisiran in cardiac ATTR amyloidosis are still being investigated.<ref name="Gertz_2020" />
-In 2021, in a clinical trial using the [[CRISPR]] gene-editing technique, several participants had an "80% to 96% drop in TTR levels, on par or better than the average of 81%" who were given [[patisiran]].<ref>{{cite journal | vauthors = Gillmore JD, Gane E, Taubel J, Kao J, Fontana M, Maitland ML, Seitzer J, O'Connell D, Walsh KR, Wood K, Phillips J, Xu Y, Amaral A, Boyd AP, Cehelsky JE, McKee MD, Schiermeier A, Harari O, Murphy A, Kyratsous CA, Zambrowicz B, Soltys R, Gutstein DE, Leonard J, Sepp-Lorenzino L, Lebwohl D | display-authors = 6 | title = CRISPR-Cas9 In Vivo Gene Editing for Transthyretin Amyloidosis | journal = The New England Journal of Medicine | volume = 385 | issue = 6 | pages = 493–502 | date = August 2021 | pmid = 34215024 | doi = 10.1056/NEJMoa2107454 | s2cid = 235722446 }}</ref>
+In 2021, in a clinical trial using the [[CRISPR]] gene-editing technique, several participants had an "80% to 96% drop in TTR levels, on par or better than the average of 81%" who were given patisiran.<ref>{{cite journal | vauthors = Gillmore JD, Gane E, Taubel J, Kao J, Fontana M, Maitland ML, Seitzer J, O'Connell D, Walsh KR, Wood K, Phillips J, Xu Y, Amaral A, Boyd AP, Cehelsky JE, McKee MD, Schiermeier A, Harari O, Murphy A, Kyratsous CA, Zambrowicz B, Soltys R, Gutstein DE, Leonard J, Sepp-Lorenzino L, Lebwohl D | display-authors = 6 | title = CRISPR-Cas9 In Vivo Gene Editing for Transthyretin Amyloidosis | journal = The New England Journal of Medicine | volume = 385 | issue = 6 | pages = 493–502 | date = August 2021 | pmid = 34215024 | doi = 10.1056/NEJMoa2107454 | s2cid = 235722446 | doi-access = free }}</ref>
 [[Vutrisiran]] was approved by the U.S. [[Food and Drug Administration]] (FDA) in June 2022, for the treatment of the polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults.<ref name="Alnylam PR 20220613">{{cite web | title=Alnylam Announces FDA Approval of Amvuttra (vutrisiran), an RNAi Therapeutic for the Treatment of the Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis in Adults | publisher=Alnylam | via=Business Wire | date=13 June 2022 | url=https://www.businesswire.com/news/home/20220603005487/en/Alnylam-Announces-FDA-Approval-of-AMVUTTRA%E2%84%A2-vutrisiran-an-RNAi-Therapeutic-for-the-Treatment-of-the-Polyneuropathy-of-Hereditary-Transthyretin-Mediated-Amyloidosis-in-Adults | access-date=14 June 2022 | archive-date=14 June 2022 | archive-url=https://web.archive.org/web/20220614055318/https://www.businesswire.com/news/home/20220603005487/en/Alnylam-Announces-FDA-Approval-of-AMVUTTRA%E2%84%A2-vutrisiran-an-RNAi-Therapeutic-for-the-Treatment-of-the-Polyneuropathy-of-Hereditary-Transthyretin-Mediated-Amyloidosis-in-Adults | url-status=live }}</ref>
 ===Support groups===
-People affected by amyloidosis are supported by organizations, including the Amyloidosis Research Consortium, Amyloidosis Foundation, Amyloidosis Support Groups, and Amyloidosis Australia.<ref>{{Cite web|url=http://rarediseases.org/rare-diseases/amyloidosis/#supporting-organizations|title=Amyloidosis - NORD (National Organization for Rare Disorders)|website=NORD (National Organization for Rare Disorders)|language=en-US|access-date=15 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160316000132/http://rarediseases.org/rare-diseases/amyloidosis/#supporting-organizations|archive-date=16 March 2016}}</ref><ref>{{Cite web|url=https://rarediseases.info.nih.gov/gard/132/amyloidosis-primary-cutaneous/resources/5|title=Amyloidosis primary cutaneous – Disease – Organizations – Genetic and Rare Diseases Information Center (GARD) – NCATS Program|website=rarediseases.info.nih.gov|access-date=15 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160315234848/https://rarediseases.info.nih.gov/gard/132/amyloidosis-primary-cutaneous/resources/5|archive-date=15 March 2016}}</ref>
+People affected by amyloidosis are supported by organizations, including the Amyloidosis Research Consortium, Amyloidosis Foundation, Amyloidosis Support Groups, and Australian Amyloidosis Network.<ref>{{cite web|url=http://rarediseases.org/rare-diseases/amyloidosis/#supporting-organizations|title=Amyloidosis - NORD (National Organization for Rare Disorders)|website=NORD (National Organization for Rare Disorders)|language=en-US|access-date=15 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160316000132/http://rarediseases.org/rare-diseases/amyloidosis/#supporting-organizations|archive-date=16 March 2016}}</ref><ref>{{cite web|url=https://rarediseases.info.nih.gov/gard/132/amyloidosis-primary-cutaneous/resources/5|title=Amyloidosis primary cutaneous – Disease – Organizations – Genetic and Rare Diseases Information Center (GARD) – NCATS Program|website=rarediseases.info.nih.gov|access-date=15 March 2016|url-status=live|archive-url=https://web.archive.org/web/20160315234848/https://rarediseases.info.nih.gov/gard/132/amyloidosis-primary-cutaneous/resources/5|archive-date=15 March 2016}}</ref>
 == Prognosis ==
@@ Line 428: / Line 426: @@
 Outcomes in a person with AA amyloidosis depend on the underlying disease, organ(s) affected, and correlate with the concentration of serum amyloid A protein.<ref name="Gertz_2020"/>
-People with ATTR, mutant ATTR and wild-type ATTR have a better prognosis when compared to people with AL and may survive for over a decade.<ref name="Falk_1997"/><ref name = "Xin_2019">{{cite journal | vauthors = Xin Y, Hu W, Chen X, Hu J, Sun Y, Zhao Y | title = Prognostic impact of light-chain and transthyretin-related categories in cardiac amyloidosis: A systematic review and meta-analysis | journal = Hellenic Journal of Cardiology | volume = 60 | issue = 6 | pages = 375–383 | date = November 2019 | pmid = 30742933 | doi = 10.1016/j.hjc.2019.01.015 | s2cid = 73419672 }}</ref> Survival time is not associated with gender or age, however, some measures of reduced heart function are associated with a shorter survival time.<ref name = "Xin_2019" />
+People with ATTR, mutant ATTR and wild-type ATTR have a better prognosis when compared to people with AL and may survive for over a decade.<ref name="Falk_1997"/><ref name = "Xin_2019">{{cite journal | vauthors = Xin Y, Hu W, Chen X, Hu J, Sun Y, Zhao Y | title = Prognostic impact of light-chain and transthyretin-related categories in cardiac amyloidosis: A systematic review and meta-analysis | journal = Hellenic Journal of Cardiology | volume = 60 | issue = 6 | pages = 375–383 | date = November 2019 | pmid = 30742933 | doi = 10.1016/j.hjc.2019.01.015 | s2cid = 73419672 | doi-access = free }}</ref> Survival time is not associated with gender or age, however, some measures of reduced heart function are associated with a shorter survival time.<ref name = "Xin_2019" />
 Senile systemic amyloidosis was determined to be the primary cause of death for 70% of [[supercentenarian|people over 110]] who have been [[Autopsy|autopsied]].<ref>{{cite journal | vauthors = Coles LS, Young RD | title = Supercentenarians and transthyretin amyloidosis: the next frontier of human life extension | journal = Preventive Medicine | volume = 54 | issue = Suppl | pages = S9-11 | date = May 2012 | pmid = 22579241 | doi = 10.1016/j.ypmed.2012.03.003 }}</ref><ref>{{cite web |url=http://www.supercentenarian.com/archive/oldest-old.html |title=Searching for the Secrets of the Super Old |publisher=Science |pages=1764–1765 |date=26 September 2008 |access-date=22 February 2013 |url-status=live |archive-url=https://web.archive.org/web/20130309054106/http://supercentenarian.com/archive/oldest-old.html |archive-date=9 March 2013}}</ref>
@@ Line 437: / Line 435: @@
 AL has the highest incidence at approximately 12 cases per million persons per year and an estimated prevalence of 30,000 to 45,000 cases in the US and European Union.<ref name="Lin_2017" /><ref name="Gertz_2020"/>
-AA amyloidoses is the most common form in developing countries and can complicate longstanding infections with [[tuberculosis]], [[osteomyelitis]], and [[bronchiectasis]]. AA amyloidosis is caused by an increase in extracellular deposition of serum amyloid A (SAA) protein. SAA protein levels can rise in both direct and indirect manners, through infection, inflammation, and malignancies.<ref>{{cite journal | vauthors = Brunger AF, Nienhuis HL, Bijzet J, Hazenberg BP | title = Causes of AA amyloidosis: a systematic review | journal = Amyloid | volume = 27 | issue = 1 | pages = 1–12 | date = March 2020 | pmid = 31766892 | doi = 10.1080/13506129.2019.1693359 | s2cid = 208299494 }}</ref> The most common causes of AA amyloidosis in the West are rheumatoid arthritis, inflammatory bowel disease, psoriasis, and [[familial Mediterranean fever]].<ref name="Falk_1997" />
+AA amyloidoses is the most common form in developing countries and can complicate longstanding infections with [[tuberculosis]], [[osteomyelitis]], and [[bronchiectasis]]. AA amyloidosis is caused by an increase in extracellular deposition of serum amyloid A (SAA) protein. SAA protein levels can rise in both direct and indirect manners, through infection, inflammation, and malignancies.<ref>{{cite journal | vauthors = Brunger AF, Nienhuis HL, Bijzet J, Hazenberg BP | title = Causes of AA amyloidosis: a systematic review | journal = Amyloid | volume = 27 | issue = 1 | pages = 1–12 | date = March 2020 | pmid = 31766892 | doi = 10.1080/13506129.2019.1693359 | s2cid = 208299494 | doi-access = free }}</ref> The most common causes of AA amyloidosis in the West are rheumatoid arthritis, inflammatory bowel disease, psoriasis, and [[familial Mediterranean fever]].<ref name="Falk_1997" />
 People undergoing long-term hemodialysis (14–15 years) can develop amyloidosis from accumulation of light chains of the HLA 1 complex which is normally filtered out by the kidneys.<ref name="Ebert_2008">{{cite journal | vauthors = Ebert EC, Nagar M | title = Gastrointestinal manifestations of amyloidosis | journal = The American Journal of Gastroenterology | volume = 103 | issue = 3 | pages = 776–787 | date = March 2008 | doi = 10.1111/j.1572-0241.2007.01669.x | pmid = 18076735 | s2cid = 25431033 }}</ref>
-Wild-type transthyretin (ATTR) amyloidosis is found in a quarter of elderly at postmortem.<ref>{{Cite journal |last1=Tanskanen |first1=Maarit |last2=Peuralinna |first2=Terhi |last3=Polvikoski |first3=Tuomo |last4=Notkola |first4=Irma‐Leena |last5=Sulkava |first5=Raimo |last6=Hardy |first6=John |last7=Singleton |first7=Andrew |last8=Kiuru‐Enari |first8=Sari |last9=Paetau |first9=Anders |last10=Tienari |first10=Pentti J. |last11=Myllykangas |first11=Liisa |date=1 January 2008 |title=Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2‐macroglobulin and tau: A population‐based autopsy study |url=https://doi.org/10.1080/07853890701842988 |journal=Annals of Medicine |volume=40 |issue=3 |pages=232–239 |doi=10.1080/07853890701842988 |issn=0785-3890 |pmid=18382889 |s2cid=23446885 |access-date=18 March 2022 |archive-date=14 June 2022 |archive-url=https://web.archive.org/web/20220614060315/https://www.tandfonline.com/doi/full/10.1080/07853890701842988 |url-status=live }}</ref> ATTR is found in 13-19% of people experiencing [[heart failure]] with preserved ejection fraction, making it a very common form of systemic amyloidosis.<ref>{{cite journal | vauthors = Hasib Sidiqi M, Gertz MA | title = Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021 | journal = Blood Cancer Journal | volume = 11 | issue = 5 | pages = 90 | date = May 2021 | pmid = 33993188 | pmc = 8124067 | doi = 10.1038/s41408-021-00483-7 }}</ref>
+Wild-type transthyretin (ATTR) amyloidosis is found in a quarter of elderly at postmortem.<ref>{{cite journal |last1=Tanskanen |first1=Maarit |last2=Peuralinna |first2=Terhi |last3=Polvikoski |first3=Tuomo |last4=Notkola |first4=Irma-Leena |last5=Sulkava |first5=Raimo |last6=Hardy |first6=John |last7=Singleton |first7=Andrew |last8=Kiuru-Enari |first8=Sari |last9=Paetau |first9=Anders |last10=Tienari |first10=Pentti J. |last11=Myllykangas |first11=Liisa |date=1 January 2008 |title=Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2-macroglobulin and tau: A population-based autopsy study |url=https://doi.org/10.1080/07853890701842988 |journal=Annals of Medicine |volume=40 |issue=3 |pages=232–239 |doi=10.1080/07853890701842988 |issn=0785-3890 |pmid=18382889 |s2cid=23446885 |access-date=18 March 2022 |archive-date=14 June 2022 |archive-url=https://web.archive.org/web/20220614060315/https://www.tandfonline.com/doi/full/10.1080/07853890701842988 |url-status=live }}</ref> ATTR is found in 13–19% of people experiencing [[heart failure]] with preserved ejection fraction, making it a very common form of systemic amyloidosis.<ref>{{cite journal | vauthors = Hasib Sidiqi M, Gertz MA | title = Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021 | journal = Blood Cancer Journal | volume = 11 | issue = 5 | pages = 90 | date = May 2021 | pmid = 33993188 | pmc = 8124067 | doi = 10.1038/s41408-021-00483-7 }}</ref>
 ==Research==
-Treatments for ATTR-related [[neuropathy]] include TTR-specific [[oligonucleotides]] in the form of [[small interfering RNA]] (patisiran) or [[antisense]] inotersen,<ref>{{cite journal | vauthors = Buxbaum JN | title = Oligonucleotide Drugs for Transthyretin Amyloidosis | journal = The New England Journal of Medicine | volume = 379 | issue = 1 | pages = 82–85 | date = July 2018 | pmid = 29972750 | doi = 10.1056/nejme1805499 | s2cid = 49658028 }}</ref> the former having recently received FDA approval.<ref>{{Cite web|url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm616518.htm|title=Press Announcements - FDA approves first-of-its kind targeted RNA-based therapy to treat a rare disease|author=Office of the Commissioner|website=www.fda.gov|language=en|access-date=11 August 2018|archive-date=7 September 2018|archive-url=https://web.archive.org/web/20180907185856/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm616518.htm|url-status=live}}</ref> Research into treatments for ATTR amyloidosis have compared liver transplantation, oral drugs that stabilize the misfolding protein (including tafamidis and diflunisal), and newer therapeutic agents still being investigated (including patisiran).<ref name="Cristóbal_Gutiérrez_2020">{{cite journal | vauthors = Cristóbal Gutiérrez H, Pelayo-Negro AL, Gómez Gómez D, Martín Vega MÁ, Valero Domínguez M | title = Overview of treatments used in transthyretin-related hereditary amyloidosis: a systematic review | journal = European Journal of Hospital Pharmacy | volume = 27 | issue = 4 | pages = 194–201 | date = July 2020 | pmid = 32587078 | pmc = 7335620 | doi = 10.1136/ejhpharm-2018-001823 }}</ref>  Based on available research, liver transplant remains the most effective treatment option for advanced ATTR amyloidosis, protein stabilizing drugs may slow disease progression but were insufficient to justify delay of liver transplant, and newer agents such as patisiran require additional studies.<ref name="Cristóbal_Gutiérrez_2020" />
+Treatments for ATTR-related [[neuropathy]] include TTR-specific [[oligonucleotides]] in the form of [[small interfering RNA]] (patisiran) or [[antisense]] inotersen,<ref>{{cite journal | vauthors = Buxbaum JN | title = Oligonucleotide Drugs for Transthyretin Amyloidosis | journal = The New England Journal of Medicine | volume = 379 | issue = 1 | pages = 82–85 | date = July 2018 | pmid = 29972750 | doi = 10.1056/nejme1805499 | s2cid = 49658028 }}</ref> the former having recently received FDA approval.<ref>{{cite web|url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm616518.htm|title=Press Announcements - FDA approves first-of-its kind targeted RNA-based therapy to treat a rare disease|author=Office of the Commissioner|website=www.fda.gov|language=en|access-date=11 August 2018|archive-date=7 September 2018|archive-url=https://web.archive.org/web/20180907185856/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm616518.htm|url-status=live}}</ref> Research into treatments for ATTR amyloidosis have compared liver transplantation, oral drugs that stabilize the misfolding protein (including tafamidis and diflunisal), and newer therapeutic agents still being investigated (including patisiran).<ref name="Cristóbal_Gutiérrez_2020">{{cite journal | vauthors = Cristóbal Gutiérrez H, Pelayo-Negro AL, Gómez Gómez D, Martín Vega MÁ, Valero Domínguez M | title = Overview of treatments used in transthyretin-related hereditary amyloidosis: a systematic review | journal = European Journal of Hospital Pharmacy | volume = 27 | issue = 4 | pages = 194–201 | date = July 2020 | pmid = 32587078 | pmc = 7335620 | doi = 10.1136/ejhpharm-2018-001823 }}</ref>&nbsp;
+Based on available research, liver transplant remains the most effective treatment option for advanced ATTR amyloidosis, protein stabilizing drugs may slow disease progression but were insufficient to justify delay of liver transplant, and newer agents such as patisiran require additional studies.<ref name="Cristóbal_Gutiérrez_2020" />
 == See also ==
@@ Line 454: / Line 454: @@
 == External links ==
-* {{Curlie|Health/Conditions_and_Diseases/Nutrition_and_Metabolism_Disorders/Inherited/Amyloidosis/}}
 {{Medical condition classification and resources
@@ Line 465: / Line 464: @@
  | eMedicineSubj = med
  | eMedicineTopic = 3377
  | eMedicine_mult =
  | MeshID = D000686
 }}

Classification	D ICD-10: E85 ICD-9-CM: 277.3 MeSH: D000686 DiseasesDB: 633
External resources	eMedicine: med/3377 Patient UK: Amyloidosis