Nontransplant Therapy for Dialysis‐Related Amyloidosis

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Abstract
There is no specific treatment for dialysis-related amyloidosis (DRA). Available therapy is directed at removal of large quantities of β2-microglobulin (β2M) and palliation of symptoms. Plasma concentrations of β2M in end-stage renal disease (ESRD) depend on the degree of residual renal function, the type of blood purification therapy, and properties of the dialysis filtration membrane. Retention of β2M appears to be a necessary, although not sufficient, condition for DRA. While preserving residual renal function is important, dialysis modality largely determines β2M removal. Convective dialysis treatments (hemofiltration and hemodiafiltration) remove β2M more efficiently than diffusive treatments (conventional dialysis). In addition, column adsorption of β2M can extensively remove the molecule, as can nocturnal hemodialysis. Hemodialysis membrane properties that are particularly important with regard to β2M removal include permeability, adsorptive capacity, and biocompatibility. As such, β2M removal with highly permeable biocompatible membranes such as polysulfone and polyacrylonitrile is relatively large. Several studies have suggested that use of such membranes can significantly delay DRA development and may be useful in ameliorating DRA-associated symptoms. Non-dialysis-related therapy for DRA is palliative and includes both medical and surgical therapies. Medical therapy includes low-dose corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical therapy consists of relief of carpal tunnel syndrome, or palliation of shoulder pain, destroyed weight-bearing joints, or spinal cord compression. DRA is a serious complication of long-term dialysis. It is important for nephrologists to recognize the condition and attempt to slow its progression.