AL Amyloidosis and renal complications

1. AL Amyloidosis and renal complications Alex Legg PhD Scientific Affairs Manager The Binding Site alex.legg@bindingsite.com Distributor in Poland BIOKOM beata.olsz@biokom.com.pl

2. organisation of light chain aggregates Characteristic organ/tissue injury Light chain physico-chemical properties Location of deposits Why are FLCs associated with kidney disease? In plasma cell dyscrasias toxic monoclonal FLCs are produced:

3. Acute tubular necrosis Fanconi’s syndrome AL amyloid LCDD AL Cast nephropathy CN 868 AL Amyloidosis patients Kidney involvement 72% Nephrotic syndrome 52% Renal failure (creat >2mg/dL) 18% Merlini, G. et al. 2008. 2(1): p. 287 - 293.

4. AL Amyloidosis Diagnosis Monoclonal Protein Investigations Serum electrophoresis: SPE + sIFE + Urine electrophoresis: UPE + uIFE and/or? Serum FLC assay

5. AL Amyloidosis • SPE • sensitivity IFE sensitivity - Lachmann H. et al. BJH 2003; 122 :78-84

6. ‘Urine IFE did not add any additional information.’ Katzmann et al. Clin Chem 2005; 51: 878-881

7. All three assays are complementary Palladini et al. Clin Chem 2009; 55: 499-503

8. AL Amyloidosis Guidelines Summary Screening

9. Kappa FLC Lambda FLC Polyclonal sFLC increase as GFR decreases Hutchison Clin J Am Soc Nephrol 3: 1684–1690, 2008

10. / ratio increases as GFR decreases New renal reference range for ratio: 0.37 – 3.1 Hutchison Clin J Am Soc Nephrol 3: 1684–1690, 2008

11. Can sFLC assays be used to diagnose multiple myeloma in patients with renal failure? • Audit of 142 patients with new dialysis dependent acute renal failure • 41 / 142 patients with multiple myeloma Hutchison et al. BMC Nephrology 2008, 9:11

12. New reference range for / ratio for renal impairment Proposed renal range / = 0.37 – 3.1 ARF - Myeloma () ARF - Myeloma () ARF - No MG 1,000 Normal sera Normal / ratio 0.26 – 1.65 Serum lambda FLC (mg/L) 10 0.1 0.1 10 1,000 Serum kappa FLC (mg/L) Hutchison et al. BMC Nephrology 2008, 9:11

13. New reference range for / ratio for renal impairment • Interpret sFLC results in the context of clinical findings and other laboratory tests… including renal function • If patient has renal impairment, then renal reference range (/ = 0.37 – 3.1) may be applicable • Renal reference range improves diagnostic specificity without changing diagnostic sensitivity

14. AL Amyloidosis Treatment Serum amyloid P scans: Reduction of AL deposits in the liver and spleen after one year of chemotherapy

15. AL amyloidosis: BD response “..at least a 50% reduction occurred in all [responding] patients within two courses of treatment.” Progressive disease Kastritis Haematologica 2007; 92: 1351 - 1358

16. Definition of treatment Response Gertz et al., Am J Hematol, 2005: 79, 319-328

17. AL amyloidosis: Outcome Gertz et al., Curr Opin Oncol 2007. 19; 136-141

18. AL Amyloidosis Guidelines Summary Monitoring

19. Utility in monitoring: Brockhurst I. et al. Nephrol Dial Transplant 2005; 20: 1251 - 1253 Light chain deposition disease 2 large published studies: • Mayo Clinic n = 19 abnormal sFLC ratio 89% • NAC n = 17 abnormal sFLC ratio 88% Katzmann J. et al. Clin Chem 2002; 48: 1437 - 1444 Wechalekar A. et al. Haematologica 2005; 90: 1414

20. Number of AL amyloidosis/ LCDD diagnoses Serum FLC Gregorini, et al. 2008. Haematologica. 2(2): E41

21. Myeloma and renal insufficiency 10 – 20% myeloma patients present with acute renal failure 10% remain dialysis dependent long term There is a high mortality rate Chemotherapy and transplantation are hazardous Cast Nephropathy:

22. Light chain removal strategies for cast nephropathy • Plasma exchange • Used since 1980s • Haemodialysis • New treatment strategy

23. Plasma exchange to remove sFLCs Challenges: • >80% of FLCs are extravascular. • PE procedures are of limited frequency & duration (typically 6 x 1.5 hour sessions over 2 weeks) Typical recovery rates: 10 - 20%.

24. Control Plasma exchange Randomised control trial of plasma exchange 100 % 80 % 60 % Cumulative survival 40 % 20 % 0 % 0 1 2 3 4 5 6 Time to death (months) Clark et al. Ann Intern Med 2005 143:777 – 84

25. Haemodialysis to remove sFLCs • 7 dialysers evaluated in vitro for filtration efficiency • The Gambro HCO 1100* was the most efficient at removing FLC * Available in Poland Hutchison, CA. et al. JASN 2007; 18: 886-895

26. High Cut-Off High Flux Plasma Filter Distribution of filter pore sizes Pore size [m] Size of albumin

27. Patient 3: 3000 Dexamethasone 2500 Velcade 2000 Pre-dialysis FLC Post-dialysis FLC Serum lambda FLC (mg/L) 1500 1000 500 0 0 5 10 15 20 25 30 Days Hutchison, CA. et al. JASN 2007; 18: 886-895

28. Resolution of Cast Nephropathy Renal biopsies: Haematoxylin and eosin stain A: Presentation B: After chemotherapy/ HCO1100 treatment Basnayake et al. 2008. J Med Case Reports; 2, ePub

29. Pilot study: Renal recovery rates 28 days Hutchison, CA. et al. 2009. Clin JASN 4, 745-54

30. European Trial of Free Light Chain Removal by Extended Haemodialysis in Cast Nephropathy Contact: Dr Colin Hutchison cah692@bham.ac.uk AL amyloidosis? Publication in press

31. Guidelines Summary N/A + sIFE & uIFE N/A - 1. Dispenzieri, A., et al. Leukemia, 2009. 23(2): p. 215-24 2. Bird, J.M., et al. Br J Haematol, 2004. 125(6): p. 681-700 3. Gertz, M.A., et al., Am J Hematol, 2005. 79(4): p. 319-28

32. Conclusions • alex.legg@bindingsite.com FLCs in AL amyloidosis: “The introduction of FLC assay has greatly improved the management of patients with AL amyloidosis and is now an essential tool in the care of this disease.” Prof. G. Merlini 5th International Symposium, Bath Assembly Rooms Biennial Meeting, 2008

33. New reference range for / ratio for renal impairment ARF - Myeloma () ARF - Myeloma () ARF - No MG 1,000 Normal sera Normal / ratio Serum lambda FLC (mg/L) 10 0.1 0.1 10 1,000 Serum kappa FLC (mg/L) Hutchison et al. BMC Nephrology 2008, 9:11

34. Patient inclusion criteria • Dialysis dependent renal failure, renal biopsy proven cast nephropathy • Fulfils diagnostic criteria for the diagnosis of symptomatic de novo MM • Abnormal sFLC ratio and sFLC > 500 mg/L • Informed consent • Commencement of study within 10 days of presentation

35. Serum negative Urine positive n = 16 Frequency Monoclonal urine FLC (g/day) Serum Positive Urine negative n = 52 Frequency Total: 219 patients sFLC concentrations (mg/L Mead, G.P., et al., Clin Lymphoma Myeloma, 2009. February: p. 153a.

36. AL amyloidosis: Serum FLC negative and urine positive? Patient X: Serum FLCs before developing AL amyloidosis: Kappa: 10 mg/ L Lambda: 10 mg/ L k/l ratio: 1 Patient X then develops a very subtle AL amyloidosis tumour Kappa: 12 mg/ L Lambda: 8 mg/ L k/l ratio: 1.5 Normal Normal This patient would normally be urine negative due to normal kidney function......

37. Renal Metabolism of FLC Glomerulus damaged by amyloids sIF + sFLC: 98% sIF + sFLC + uIF: 100% Albumin saturates proximal tubule Weakly positive urine

38. Randomised and controlled 90 Patients recruited Randomisation Control Arm HD 45 Patients Standard high-flux HD Research Arm HD 45 Patients Extended HD on HCO 1100 ‘Modified PAD regimen’ Chemotherapy (P) VELCADE™ (bortezomib) iv 1.0 mg/m2 (A) Adriamycin (Doxorubicin) iv 9.0 mg/m2 (D) Dexamethasone oral 40 mg Assess outcome

39. Trial time course • sFLC measured • at assessment Run within 24 hours • pre dialysis • post dialysis • non-dialysis Run once /week

40. Four variables that had maximum impact on the outcome: FLCdifference troponin-T BNP B2M Kumar, S., et al., Haematologica, 2008. 2(2): p. C19

41. 12000 10000 2 8000 3 6000 4000 2000 0 0 1 2 4 5 6 7 8 9 11 12 13 14 15 17 18 19 20 21 22 24 25 26 27 28 30 Model of sFLC Removal - PE • 100% tumour kill on day 1, RES clearance only • 10% tumour kill/day, RES clearance only • 10% tumour kill/day with PE Serum kappa (mg/L) 1 0 5 10 15 20 25 30 Time (days) Hutchison et al (2007) JASN 18, 886-895

42. 2 3 4 5 Model of sFLC Removal – HCO1100 • 100% tumour kill on day 1, RES clearance only • 10% tumour kill /day, RES clearance only • 10% tumour kill /day with PE • 10% tumour kill /day with HD (3 x 4h /week) • 10% tumour kill /day with HD (12h /day)

43. Abraham, R.S., et al., Am J Clin Pathol, 2003. 119(2): p. 274-8

44. All urine IFE+ AL amyloidosis patients identified by sIFE + sFLC Katzmann, J.A., et al., Mayo Clin Proc, 2006. 81(12): p. 1575-8.

45. Absolute FLC levels are prognostic in AL amyloidosis patients undergoing peripheral blood stem cell transplantation Higher FLC concentration correlated with: Bone marrow plasmacytosis Number of organs involved Beta-2-microglobulin Serum cardiac troponin T Dispenzieri et al. Blood, 2006; 3378-3383

46. Higher FLC concentration correlated with: Bone marrow plasmacytosis Number of organs involved Beta-2-microglobulin Serum cardiac troponin T

47. AL amyloidosis: MP response A.R. Bradwell: Serum Free LightChain Analysis 5th Edition

48. Monoclonal Protein Investigations AL Amyloidosis Diagnosis Serum electrophoresis: SPE + sIFE 100% 98% 53% Number of patients SPE quantifiable FLC 3% 26% 21% Total SPE+ SPE-/ IFE+ SPE-/ IFE- FLC Lachmann H. et al. BJH 2003; 122 :78-84

49. Absolute FLC levels are prognostic in AL amyloidosis patients undergoing peripheral blood stem cell transplantation Dispenzieri et al. Blood, 2006; 3378-3383

50. Comparison SAP scans and serum FLCs in 127 AL amyloidosis patients before and 12 months after chemotherapy. Lachmann, H.J., et al., Br J Haematol, 2003. 122(1): p. 78-84