Screening Panels for Monoclonal Gammopathies: Time to Change

The introduction of quantitative assays for serum free light chains (FLC) has changed the approach to screening for monoclonal gammopathies. Recent guidelines from the International Myeloma Working Group have recommended the use of serum protein electrophoresis (SPEP), immunofixation electrophoresis (IFE) and FLC as the screening panel unless primary amyloidosis (AL) is suspected. If screening for AL, then urine IFE should also be performed. We discuss the background for these recommendations as well as data showing that SPEP and FLC alone may provide a simplified screening panel for detecting multiple myeloma (MM) and Waldenström’s macroglobulinaemia (WM) with little loss of diagnostic sensitivity. If AL is suspected, we support the recommendation to include serum and urine IFE. The selective use of serum and urine IFE requires that clinical judgment be integral to ordering screening panels for detection of monoclonal gammopathies.     

Quantitative Serum Free Light Chain Assay – Analytical Issues

Serum free light chain (FLC) assay is an important advance in the diagnosis and monitoring of monoclonal light chain diseases and a complementary test to serum protein electrophoresis and immunofixation. Immunoturbidimetric and immunonephelometric assays for serum FLC are available on routine chemistry analysers and can detect FLC down to ~1 mg/L. These assays use polyclonal anti-human FLC antisera and require acceptable imprecision, specificity, accuracy, and reproducibility between reagent batches to prevent under- or over-estimation of FLC concentration.Assay imprecision determined between reagent lots has a variation of 8–45% for FLC concentrations and 17–32% for the calculated κ/λ FLC ratio. Dilution studies indicate some over-recovery of FLC, which may depend upon the dilution matrix. However, greater discrepancies are underestimation from nonlinear reactions and overestimation possibly from interferences or multi-reactivity to polymeric FLC. Nonlinear monoclonal FLC give concentrations which are 2- to 6-fold increased at higher sample dilution and FLC measured on different platforms may not give the same results.Laboratory staff and clinicians should be aware of the analytical limitations of the FLC assay. Assay imprecision, especially with different lots of FLC reagent, may have a significant effect on changes in the FLC concentration and κ/λ FLC ratio. Sample dilution anomalies have the potential to confound result interpretation for patients with monoclonal light chain disease. These issues, if not adequately appreciated, have the potential to mislead clinical diagnosis and assessment of response to therapy.Serum free light chain (FLC) assay came into routine clinical laboratories following the publication in 2001 describing the presence of monoclonal FLC in 19/28 non-secretory myeloma (NSMM) patients at diagnosis.¹ Use of the assay has grown globally since that time and other retrospective clinical studies have shown the clinical utility of FLC in serum as a complementary test to serum protein electrophoresis (SPEP) for the diagnosis and monitoring of monoclonal light chain diseases.Monoclonal immunoglobulin free light chains are important tumour markers often present in serum and urine of patients with monoclonal gammopathies. Serum kappa (κ) and lambda (λ) FLC assays measure total polyclonal and monoclonal FLC in serum and the calculated κ/λ FLC ratio is a surrogate measure of clonality. Retrospective studies have shown serum FLC is clinically indicated for diagnosis and prognosis in plasma cell proliferative disorders, including primary amyloidosis (AL), NSMM, light chain multiple myeloma (LCMM), light chain deposition disease (LCDD) and solitary plasmacytoma; in documenting stringent complete response in multiple myeloma (MM); and for routine serial measurement to assess response in the oligosecretory diseases, NSMM, AL and LCDD.² Serial measurements may also be indicated in MM when serum M-protein is <10 g/L or urinary Bence Jones protein (BJP) excretion is <200 mg/24h.³ However, there is currently no data to support its use in the monitoring of MM where disease is measurable by other methods such as SPEP. (Refer also to the review on FLC by J Katzmann in this issue).     

Role of Glycosaminoglycan Sulfation in the Formation of Immunoglobulin Light Chain Amyloid Oligomers and Fibrils

Primary amyloidosis (AL) results from overproduction of unstable monoclonal immunoglobulin light chains (LCs) and the deposition of insoluble fibrils in tissues, leading to fatal organ disease. Glycosaminoglycans (GAGs) are associated with AL fibrils and have been successfully targeted in the treatment of other forms of amyloidosis. We investigated the role of GAGs in LC fibrillogenesis. Ex vivo tissue amyloid fibrils were extracted and examined for structure and associated GAGs. The GAGs were detected along the length of the fibril strand, and the periodicity of heparan sulfate (HS) along the LC fibrils generated in vitro was similar to that of the ex vivo fibrils. To examine the role of sulfated GAGs on AL oligomer and fibril formation in vitro, a κ1 LC purified from urine of a patient with AL amyloidosis was incubated in the presence or absence of GAGs. The fibrils generated in vitro at physiologic concentration, temperature, and pH shared morphologic characteristics with the ex vivo κ1 amyloid fibrils. The presence of HS and over-O-sulfated-heparin enhanced the formation of oligomers and fibrils with HS promoting the most rapid transition. In contrast, GAGs did not enhance fibril formation of a non-amyloidogenic κ1 LC purified from urine of a patient with multiple myeloma. The data indicate that the characteristics of the full-length κ1 amyloidogenic LC, containing post-translational modifications, possess key elements that influence interactions of the LC with HS. These findings highlight the importance of the variable and constant LC regions in GAG interaction and suggest potential therapeutic targets for treatment.     

Effect of lysine modification on the stability and cellular binding of human amyloidogenic light chains

AL amyloidosis is characterized by the pathologic deposition as fibrils of monoclonal light chains (i.e., Bence Jones proteins [BJPs]) in particular organs and tissues. This phenomenon has been attributed to the presence in amyloidogenic proteins of particular amino acids that cause these molecules to become unstable, as well as post-translational modifications and, in regard to the latter, we have investigated the effect of biotinylation of lysyl residues on cell binding. We utilized an experimental system designed to test if BJPs obtained from patients with AL amyloidosis or, as a control, multiple myeloma (MM), bound human fibroblasts and renal epithelial cells. As documented by fluorescence microscopy and ELISA, the amyloidogenic BJPs, as compared with MM components, bound preferentially and this reactivity increased significantly after chemical modification of their lysyl residues with sulfo-NHS-biotin. Further, based on tryptophan fluorescence and circular dichroism data, it was apparent that their conformation was altered, which we hypothesize exposed a binding site not accessible on the native protein. The results of our studies indicate that post-translational structural modifications of pathologic light chains can enhance their capacity for cellular interaction and thus may contribute to the pathogenesis of AL amyloidosis and multiple myeloma.     

The antisense approach in amyloid light chain amyloidosis: identification of monoclonal Ig and inhibition of its production by antisense oligonucleotides in in vitro and in vivo models

Primary amyloid L chain (AL) amyloidosis is a plasma cell disorder in which depositions of AL cause progressive organ failure. The lack of effective therapies for this fatal disease prompts exploration of newer treatment avenues. We have investigated the application of antisense oligonucleotides (AS) for the inhibition of monoclonal Ig production. The monoclonal L chain was identified by using primers designed for amplifying the human lambda Ig V (Vlambda) region. We demonstrated that AS against L chain complementarity-determining regions inhibited the production of L chain in vitro. RPMI 8226 myeloma cells injected in SCID mice developed s.c. tumors. RT-PCR analysis showed Vlambda mRNA expression in the tumors. In addition, the presence of human Ig in the sera of mice given injection of RPMI 8226 cells was confirmed by ELISA. Administration of AS inhibited the expression of Vlambda mRNA in the s.c. tumors and decreased the concentration of L chain in serum. Therefore, we have shown that it is possible to determine the sequence of Vlambda mRNA and design specific complementary oligonucleotides, suggesting that treatment with Vlambda antisense could represent a rational novel approach to improve treatment outcome in AL amyloidosis.     

Cardiac amyloidosis: the need for early diagnosis

Amyloidosis is a collection of systemic diseases characterised by misfolding of previously soluble precursor proteins that become infiltrative depositions, thereby disrupting normal organ structure and function. In the heart, accumulating amyloid fibrils lead to progressive ventricular wall thickening and stiffness, resulting in diastolic dysfunction gradually progressing to a restrictive cardiomyopathy. The main types of cardiac amyloidosis are amyloid light chain (AL) amyloidosis caused by an underlying plasma cell dyscrasia, amyloid transthyretin (TTR) amyloidosis of wild-type (normal) TTR at older age (ATTRwt) and hereditary or mutant amyloid TTR (ATTRm) in which a genetic mutation leads to an unstable TTR protein. Overall survival is poor once heart failure develops, underlining the need for early referral and diagnosis. Treatment for AL amyloidosis has improved markedly over the last decades, and TTR amyloidosis gene silencers and orally available transthyretin stabilisers are ready to enter the clinical arena after recent positive outcome trials. Novel therapies aiming at fibril degradation with monoclonal antibodies are under investigation. In this review, we focus on ‘red flag’ signs and symptoms, diagnosis and management of cardiac amyloidosis which differs considerably from the general management of heart failure. Only by increasing awareness, prognosis for patients with this devastating disease can be improved.

     

Bortezomib Resistance Can Be Reversed by Induced Expression of Plasma Cell Maturation Markers in a Mouse In Vitro Model of Multiple Myeloma

Multiple myeloma (MM), the second most common hematopoietic malignancy, remains an incurable plasma cell (PC) neoplasm. While the proteasome inhibitor, bortezomib (Bz) has increased patient survival, resistance represents a major treatment obstacle as most patients ultimately relapse becoming refractory to additional Bz therapy. Current tests fail to detect emerging resistance; by the time patients acquire resistance, their prognosis is often poor. To establish immunophenotypic signatures that predict Bz sensitivity, we utilized Bz-sensitive and -resistant cell lines derived from tumors of the Bcl-X_L/Myc mouse model of PC malignancy. We identified significantly reduced expression of two markers (CD93, CD69) in “acquired” (Bz-selected) resistant cells. Using this phenotypic signature, we isolated a subpopulation of cells from a drug-naïve, Bz-sensitive culture that displayed “innate” resistance to Bz. Although these genes were identified as biomarkers, they may indicate a mechanism for Bz-resistance through the loss of PC maturation which may be induced and/or selected by Bz. Significantly, induction of PC maturation in both “acquired” and “innate” resistant cells restored Bz sensitivity suggesting a novel therapeutic approach for reversing Bz resistance in refractory MM.     

Light Chain Amyloid Fibrils Cause Metabolic Dysfunction in Human Cardiomyocytes

Light chain (AL) amyloidosis is the most common form of systemic amyloid disease, and cardiomyopathy is a dire consequence, resulting in an extremely poor prognosis. AL is characterized by the production of monoclonal free light chains that deposit as amyloid fibrils principally in the heart, liver, and kidneys causing organ dysfunction. We have studied the effects of amyloid fibrils, produced from recombinant λ6 light chain variable domains, on metabolic activity of human cardiomyocytes. The data indicate that fibrils at 0.1 μM, but not monomer, significantly decrease the enzymatic activity of cellular NAD(P)H-dependent oxidoreductase, without causing significant cell death. The presence of amyloid fibrils did not affect ATP levels; however, oxygen consumption was increased and reactive oxygen species were detected. Confocal fluorescence microscopy showed that fibrils bound to and remained at the cell surface with little fibril internalization. These data indicate that AL amyloid fibrils severely impair cardiomyocyte metabolism in a dose dependent manner. These data suggest that effective therapeutic intervention for these patients should include methods for removing potentially toxic amyloid fibrils.     

Establishment of a first-order kinetic model of light chain-associated amyloid fibril extension in vitro

Light chain-associated (AL) amyloidosis is a common and fatal systemic amyloidosis. AL amyloid fibrils (fAL) are composed of intact or fragmental monoclonal light chains (AL proteins). To elucidate the molecular mechanisms of fAL formation from AL proteins, we purified fAL and AL proteins from the amyloid-deposited organs of five AL amyloidosis patients. By electron microscopy and fluorometric thioflavin T method, we observed optimal fibril extension at pH 2.0-3.5 for the fibrils obtained from four patients, while at pH 7.5-8.0 for those obtained from one patient. Fragmental AL proteins were more efficient in the extension reaction than intact AL proteins. The fibrils obtained from all five patients showed clear fibril extension electron microscopically at pH 7.5. The extension of the fibrils obtained from all five patients could be explained by a first-order kinetic model, i.e., fibril extension proceeds via the consecutive association of AL proteins onto the ends of existing fibrils. Fibril extension was accelerated by dermatan sulfate proteoglycan, and inhibited by apolipoprotein E, alpha1-microglobulin, fibronectin, and an antioxidant nordihydroguaiaretic acid. These findings contribute to our understanding of the molecular mechanism underlying the pathogenesis of AL amyloidosis, and will be useful for developing a therapeutic strategy against the disease.     

Generation of T cell clones binding F(ab′)2 fragments of the idiotypic immunoglobulin in patients with monoclonal gammopathy

Summary Lymphocytes from two patients with multiple myeloma stage I and one patient with monoclonal gammopathy of undetermined significance were found to proliferate specifically in response to low concentrations of F(ab)₂ fragments of the autologous M component. T cell clones isolated from repeatedly stimulated cultures bound specifically the autologous idiotype and proliferated after addition of soluble idiotype and exogenous interleukin-2. The majority of clones were CD8⁺ and showed negligible staining for CD4. Idiotype-binding clones could not be isolated from cultures of lymphocytes from a healthy control stimulated under the same conditions. The study provides support for the existence of idiotype-reactive T cells in monoclonal gammopathies. Such cells might have a regulatory role on the tumour cell clone and may be important for a future therapeutic approach.     

Differences in immunoglobulin light chain species found in urinary exosomes in light chain amyloidosis (Al)

Renal involvement is a frequent consequence of plasma cell dyscrasias. The most common entities are light chain amyloidosis, monoclonal immunoglobulin deposition disease and myeloma cast nephropathy. Despite a common origin, each condition has its own unique histologic and pathophysiologic characteristic which requires a renal biopsy to distinguish. Recent studies have shown urinary exosomes containing kidney-derived membrane and cytosolic proteins that can be used to probe the proteomics of the entire urinary system from the glomerulus to the bladder. In this study, we analyzed urine exosomes to determine the differences between exosomes from patients with light chain amyloidosis, multiple myeloma, monoclonal gammopathy of undetermined significance, and non-paraproteinemia related kidney disease controls. In patients with light chain amyloidosis, multiple myeloma and monoclonal gammopathy of undetermined significance, immunoreactive proteins corresponding to monomeric light chains were found in exosomes by western blot. In all of the amyloidosis samples with active disease, high molecular weight immunoreactive species corresponding to a decamer were found which were not found in exosomes from the other diseases or in amyloidosis exosomes from patients in remission. Few or no light chains monomeric bands were found in non-paraproteinemia related kidney disease controls. Our results showed that urinary exosomes may have tremendous potential in furthering our understanding of the pathophysiology and diagnosis of plasma cell dyscrasia related kidney diseases.     

首例RNA干扰药物问世及该领域技术演化历程

近期,RNA干扰(RNAi)制药公司Alnylam开发的小干扰RNA (siRNA)药物ONPATTRO?美国食品与药物管理局和欧盟委员会批准上市,用于治疗成人患者的遗传性转甲状腺素蛋白淀粉样变性引起的多发性神经病变.这是全球第一款RNAi药物,该事件标志着人类继小分子化合物、单克隆抗体蛋白类药物后,在前沿生物制药领域实现了新的突破,意味着RNAi疗法从基础研究到临床治疗的开发全过程首次贯通,具有里程碑式的意义.本文概述了该药物及适应症的基本情况,介绍了RNAi发现历史、作用机理与药物特征,RNAi药物的研发历程,以及该领域关键技术的最新研究进展.     

The future of monoclonal antibody technology

With the rapid growth of monoclonal antibody-based products, new technologies have emerged for creating modified forms of antibodies, including fragments, conjugates and multi-specific antibodies. We created a database of 450 therapeutic antibodies in development to determine which technologies and indications will constitute the “next generation” of antibody products. We conclude that the antibodies of the future will closely resemble the antibodies that have already been approved for commercial sale.Key words: monoclonal antibody, therapeutic products, bispecific antibodies, antibody conjugates     

Focus: Microbiome: The Impact of the Gut Microbiota on Drug Metabolism and Clinical Outcome

The significance of the gut microbiota as a determinant of drug pharmacokinetics and accordingly therapeutic response is of increasing importance with the advent of modern medicines characterised by low solubility and/or permeability, or modified-release. These physicochemical properties and release kinetics prolong drug residence times within the gastrointestinal tract, wherein biotransformation by commensal microbes can occur. As the evidence base in support of this supplementary metabolic “organ” expands, novel opportunities to engineer the microbiota for clinical benefit have emerged. This review provides an overview of microbe-mediated alteration of drug pharmacokinetics, with particular emphasis on studies demonstrating proof of concept in vivo. Additionally, recent advances in modulating the microbiota to improve clinical response to therapeutics are explored.     

Evolutionary dynamics of two related malignant plasma cell lines

Cancer is the consequence of sequential acquisition of mutations within somatic cells. Mutations alter the relative reproductive fitness of cells, enabling the population to evolve in time as a consequence of selection. Cancer therapy itself can select for or against specific subclones. Given the large population of tumor cells, subclones inevitably emerge and their fate will depend on the evolutionary dynamics that define the interactions between such clones. Using a combination of in vitro studies and mathematical modeling, we describe the dynamic behavior of two cell lines isolated from the same patient at different time points of disease progression and show how the two clones relate to one another. We provide evidence that the two clones coexisted at the time of initial presentation. The dominant clone presented with biopsy-proven cardiac AL amyloidosis. Initial therapy selected for the second clone that expanded leading to a change in the diagnosis to multiple myeloma. The evolutionary dynamics relating the two cell lines are discussed and a hypothesis is generated in regard to the mechanism of one of the phenotypic characteristics that is shared by these two cell lines.Key words: multiple myeloma, amyloidosis, chemotherapy, clonal evolution, selection     

RNAi therapeutic and its innovative biotechnological evolution

Recently, United States Food and Drug Administration (FDA) and European Commission (EC) approved Alnylam Pharmaceuticals' RNA interference (RNAi) therapeutic, ONPATTRO? (Patisiran), for the treatment of the polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults. This is the first RNAi therapeutic all over the world, as well as the first FDA-approved treatment for this indication. As a milestone event in RNAi pharmaceutical industry, it means, for the first time, people have broken through all development processes for RNAi drugs from research to clinic. With this achievement, RNAi approval may soar in the coming years. In this paper, we introduce the basic information of ONPATTRO and the properties of RNAi and nucleic acid therapeutics, update the clinical and preclinical development activities, review its complicated development history, summarize the key technologies of RNAi at early stage, and discuss the latest advances in delivery and modification technologies. It provides a comprehensive view and biotechnological insights of RNAi therapy for the broader audiences.     

Beyond the Range of Sound—The Non-Otological Aspects of Deafness

Historically, deaf persons were seen as less than human — as “beasts of the field” who could not speak and thus had no legal rights. With educational advances, both the achievements of deaf individuals and the attitudes of the hearing world toward them have improved. However, the total scope of impairment of early profound deafness remains considerable despite vast advances in the fields of medicine, audiology and education. Traumatic parental reaction to the diagnosis and distorted parent-child communication may contribute to the impairment. Recent research has added to our knowledge of the social and psychiatric ramifications of deafness, but a lack of mental health professionals capable of communicating with deaf persons retards progress in this area.