Dialysis-Related Beta-2m Amyloidosis 

Updated: Nov 14, 2019
Author: Anita Basu, MD, FACP; Chief Editor: Vecihi Batuman, MD, FASN 

Overview

Practice Essentials

Beta-2 ̶ microglobulin (beta-2m) amyloidosis is a disabling condition that affects patients undergoing long-term hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD).[1, 2, 3] Case reports involving patients with near ̶ end-stage renal disease also exist. The condition does not affect individuals with normal or mildly reduced renal function or patients with a functioning kidney transplant. Beta-2m amyloidosis evolves predictably over time and is rare in the first few years of HD. (See Etiology.)

Beta-2m is a major constituent of amyloid fibrils.[4] Through accumulation, it invades synovial membranes and osteoarticular sites. As a result, it causes destructive osteoarthropathies, such as carpal tunnel syndrome, flexor tenosynovitis, subchondral bone cysts, and erosions, as well as pathologic fractures. (See Etiology, Prognosis, and Presentation.)

Visceral involvement has been found in sites such as the gastrointestinal (GI) tract, heart, and tongue, but overt manifestations are rare. (See Presentation and Workup.) The most severe complication involves beta-2m amyloid deposits destroying paravertebral ligaments and intervertebral discs, which can result in paraplegia. Cardiac involvement, with subsequent fatal arrhythmias, and massive GI bleeding have been described.

Symptomatic relief in patients with beta-2m amyloidosis can be provided with analgesic and anti-inflammatory medication, physical and occupational therapy, and surgical procedures. Kidney transplantation is the treatment of choice. See Treatment.

Etiology

Beta-2m is a glycosylated polypeptide with a molecular weight of 11,800 dalton. It makes up the beta chain of the human leukocyte antigen (HLA) class I molecule and has the prominent beta-pleated structure that is characteristic of amyloid fibrils.

Beta-2m is present on the surface of most nucleated cells and in most biologic fluids, including urine and synovial fluid. It circulates as an unbound monomer distributed in the extracellular space and polymerizes to form amyloid deposits in a variety of tissues. Capillary electrophoresis recognizes 2 or 3 conformational isomers of beta-2m in human serum.[5]

In the normally functioning kidney, beta-2m is cleared by glomerular filtration and is catabolized in the proximal tubules. Reference-range serum levels are 1.5-3 mg/L. In renal failure, impaired renal catabolism causes an increase in synthesis and release of beta-2m, and levels can rise 10- to 60-fold. Retention and accumulation of this type of amyloid protein is presumed to be the main pathogenic process underlying beta-2m amyloidosis.

There is also some suggestion that the dialysis process itself may stimulate beta-2m synthesis, by activation of complements and cytokine production. However, this is probably not a significant mechanism of dialysis-related amyloidosis (DRA), since the disease is also seen in patients on CAPD and people who have never been on dialysis.

Role of dialysis in amyloidogenesis

Retention of amyloidogenic protein remains a key factor in patients on dialysis. Several factors affecting retention have been implicated, including the following:

  • Type of dialysis membrane
  • Prolonged uremic state and/or decreased diuresis
  • Elevated levels of cytokines
  • Advanced glycation end products
  • Dialysate

Type of dialysis membrane

The healthy kidney can eliminate endogenous end products of metabolism, as well as exogenous toxins that are both large- and small- molecular-weight substances. Cuprophan and cellulose acetate membranes previously used in conventional HD have small pores and cannot clear substances with molecular weights higher than 200 daltons. This makes them impermeable to beta-2m, elevating the protein’s serum levels. The newer cellulose triacetate dialyzers and the high-flux synthetic dialyzers remove molecules with a higher molecular weight and do a better job of removing beta-2m.

High cut-off, high-flux dialysis and online hemodiafiltration have been shown to be superior to previously used HD membranes in the removal of beta-2m, possibly decreasing beta-2 amyloidosis.

Beta-2m amyloidosis has also been described in patients receiving long-term CAPD, despite the permeability characteristics of the peritoneal membrane. Clearance of middle molecules is better, however, making CAPD a more biocompatible mode of treatment.

Nonetheless, data are conflicting. Some report the prevalence of beta-2m amyloidosis in patients on long-term CAPD as comparable to the prevalence in patients on HD. Other data show that plasma levels of beta-2m are lower in patients on CAPD, suggesting that amyloid may accumulate more slowly. Some of this may also be related to residual renal function. Results of long-term studies are needed.

Prolonged uremic state and/or decreased diuresis

Membranes with poor biocompatibility cannot completely explain increases in beta-2m, because several reports involve individuals who were treated exclusively with CAPD. Cases have also been described in patients with chronic renal failure who have not yet started dialysis. Inadequate diuresis and prolonged uremia are suggested contributing factors.

Elevated levels of cytokines

Dialysis is an inflammatory stimulus, inducing cytokine production and complement activation. The released cytokines, including interleukin 1 (IL-1), tumor necrosis factor-alpha (TNF-alpha), and interleukin 6 (IL-6), are thought to stimulate the synthesis and release of beta-2m by macrophages and/or augment the expression of HLA class I antigens, increasing beta-2m expression.

Advanced glycation end products

Following the identification of advanced glycation end products (AGEs) in beta-2m amyloid deposits, the role of AGE has been the focus of much research.[6]

AGEs make up a heterogeneous group of compounds formed by nonenzymatic glycation and oxidative reactions between reducing sugars, lipids, and protein amino groups.

HD and peritoneal dialysis are ineffective in removing these low-molecular-weight compounds from circulation.

As AGE-modified beta-2m accumulates, chemotaxis is enhanced, stimulating macrophages to release proinflammatory cytokines, as well as interfering with collagen synthesis. It has been suggested that the interaction of AGE-modified beta-2m with mononuclear phagocytes (MPs), cells important in the pathogenesis of the inflammatory arthropathy of DRA, is mediated by the receptor for AGEs, or RAGE.

RAGEs are central binding sites for AGEs formed in vivo.[7] AGE beta-2m/MP/RAGE interaction likely contributes to the initiation of an inflammatory response in amyloid deposits of patients on long-term HD. This inflammatory response may ultimately lead to bone and joint destruction.

Oxidation of beta-2m may enhance amyloid deposition. Studies suggest that increased oxidative stress during HD and exposure of beta-2m to hydroxyl radicals stimulate the autoxidation of unstable molecules, leading to augmented AGE production.

Dialysate

Acetate and/or bacterial lipopolysaccharide (endotoxin) may enter the blood via the dialyzer and stimulate the release of cytokines, inducing beta-2m production.

Epidemiology

The incidence of DRA in the United States is not known; however, past studies have suggested an incidence of greater than 95% in patients who have been on dialysis for more than 15 years.

Some European studies have suggested that DRA can be seen in as many as 20% of patients after 2-4 years of HD and in 100% after 13 years of HD. Again, however, the overall incidence and prevalence of beta-2m amyloidosis are not clear. Moreover, most studies have focused on HD-associated amyloidosis and were performed before high-flux dialyzer use became commonplace.

There is some mention in the literature that the incidence and prevalence of beta-2m amyloidosis are less in CAPD than in HD (because of residual renal function). Other studies, however, suggest that there is no significant difference in incidence or prevalence.[8]

Prognosis

The prognosis of beta-2m amyloidosis depends on the duration of dialysis, the age of the patient, the age of the patient at the start of dialysis, and the type of dialysis membrane that is being used. Ultimately, residual renal function is probably the best determinant of beta-2m levels in HD patients and may supersede enhanced convective clearance by hemodiafiltration.[9]

Morbidity and mortality

Patients receiving long-term dialysis can experience disabling musculoskeletal complications.[10] For individuals who are able to undergo renal transplantation, progression of the disease can be halted, but regression is unlikely. Rarely, submucosal bowel deposits have resulted in massive GI bleeding.

Case reports also exist of severe pulmonary hypertension and heart failure due to beta-2m amyloid deposits in the interstitium and/or vasculature of the cardiovascular system.

Studies in Japan have suggested that most patients with carpal tunnel syndrome associated with beta-2m amyloid deposits have undergone HD for 10 years or more. In one study, up to 50% of patients developed this complication after 20 years, and the percentage was even higher after 25 years.[11]

 

Presentation

History

Clinical manifestations of beta-2m amyloidosis almost never appear before a patient has undergone 5 years of dialysis therapy. Unlike other types of amyloids, beta-2m amyloid is confined largely to osteoarticular sites.[12]

Patients often present with a characteristic triad of carpal tunnel syndrome, shoulder pain, and flexor tenosynovitis in the hands. The rate of surgery for osteoarticular disorders, such as carpal tunnel syndrome, destructive spondyloarthropathy (DSA), and joint arthropathy, which may show the presence of dialysis-related amyloidosis (DRA), is very high.[13]

Visceral deposits are rare, occur after 10 or more years of dialysis, and tend not to cause symptoms in most cases.

Osteoarticular manifestations

Osteoarticular manifestations can include the following:

  • Carpal tunnel syndrome
  • Flexor tenosynovitis
  • Scapulohumeral arthropathy
  • Spondyloarthropathy
  • Lytic bone lesions
  • Bone cysts
  • Pathologic fractures - Caused by amyloid deposition within joints, intervertebral discs, and tendon sheaths [12]
  • Musculoskeletal deformities

Carpal tunnel syndrome

This syndrome is the most common presenting feature. It usually is bilateral and progressive.[11] Patients report numbness, paresthesias, pain, and swelling in the region of the distal median nerve. Pain usually is worse during dialysis and at night. Progression to contraction of the hand and atrophy of the muscles can occur. However, it is important to remember that not all cases of carpal tunnel syndrome in dialysis patients are amyloid related; the syndrome may arise from other causes, such as ischemia.

Flexor tenosynovitis

This disorder is often referred to as trigger finger or trigger thumb. Patients can flex the finger, but with reextension, the patient may feel a painful snap that refers to the dorsum of the hand.

Scapulohumeral arthropathy

Amyloid may deposit in and around the rotator cuff, resulting in shoulder pain that becomes worse when the patient is in the supine position. Patients often report difficulty dressing.

Spondyloarthropathy

The cervical spine is most often affected, and patients often present with neck and back pain. DSA is a major cause of hospital admissions in long-term dialysis patients, especially in patients who have undergone dialysis for 30 years or more.

Bone cysts

Thin-walled bone cysts are common and are most frequently found in the carpal bones. They are also observed in the femoral heads, humerus, patella, acetabulum, and spine. Patients may experience stiffness and/or pain over the affected area.

Fractures can develop in bones weakened by bone cysts. The femoral neck is most commonly involved. Patients may experience a sudden onset of leg pain while walking.

Systemic manifestations

Systemic manifestations are rare, and patients with systemic involvement generally are asymptomatic. Most individuals with systemic manifestations have undergone dialysis for longer than 10-15 years.

If systemic involvement does occur, small, localized deposits are observed around blood vessels and in the mucosa of the GI tract, heart, lungs, and genitourinary tract. In rare cases, fatal GI hemorrhages, cardiac arrhythmias, and renal vein thromboses have occurred.  Inflammatory symptoms are usually rare and only a few cases with fever or inflammatory arthritis have been reported.[14]

GI involvement

Macroglossia, dysphagia, small bowel ischemia, malabsorption, and pseudo-obstruction can occur because of subepithelial, submucosal, and blood vessel amyloid deposits.[15]

Cardiovascular involvement

Myocardial, pericardial, and cardiac valves may be involved. Beta-2m amyloid deposits have also been identified in small pulmonary arteries and veins.

Genitourinary tract involvement

Renal and bladder calculi containing beta-2m deposits and causing obstruction have been described. Beta-2m amyloid has also been identified in the prostate and the female reproductive tract.

Physical Examination

Systemic involvement is rare in beta-2m amyloidosis. Osteoarticular involvement can include the following:

  • Carpal tunnel syndrome - Patients experience weakness and atrophy of the thenar muscle, along with decreased strength in abduction, opposition, and flexion of the thumb

  • Flexor tenosynovitis - Amyloid deposits may result in prominence of the tendons of the hands on extension; patients often experience decreased digital mobility and soft-tissue swelling over flexor tendon sheaths

  • Scapulohumeral arthropathy - Deposits in and around the rotator cuff may cause soft-tissue thickening around the shoulder, referred to as the shoulder pad sign; the patient's capacity to abduct or internally rotate the arm is limited

  • Spondyloarthropathy - Paravertebral ligaments and intervertebral discs may be destroyed or dislocated, resulting in spinal cord impingement or paraplegia; the cervical spine is most often affected, and patients often present with neck and back pain

  • Bone cysts - Cysts grow in size and number in the wrist, humeral head, hip, and patella; as cysts enlarge, soft-tissue swelling and swollen joints, with subsequent spontaneous tendon rupture and pathologic fracture, may occur (cysts do not regress with renal transplantation)

Hoshino et al validated a clinical staging score to measure the severity of dialysis-related amyloidosis (DRA).[16] Elements of the score are as follows:

  • Polyarthralgia – 3 points
  • Dialysis-related spondyloarthropathy (DRS) – 3 points
  • Trigger finger – 2 points
  • Carpal tunnel syndrome – 2 points

DRA is staged according to the score as follows:

  • Mild (3-4 points)
  • Moderate (5-7 points)
  • Severe (8-10 points)
 

DDx

Diagnostic Considerations

Secondary hyperparathyroidism

Secondary hyperparathyroidism is the most common bone disease found in patients with end-stage renal disease. Bone erosions, tendon ruptures, and osteosclerosis can be the source of bone pain or polyarthralgias.

Renal osteodystrophy

Dialysis-related amyloidosis (DRA) bone lesions differ from renal osteodystrophy in that in DRA, the presence of the amyloid deposits interferes with normal bone-tissue dynamics, while in renal osteodystrophy, the abnormality is in the underlying metabolic process itself, causing bone turnover to be either increased or decreased.

In the case of pathologic fractures in patients on dialysis, it is essential that DRA be distinguished from renal osteodystrophy, because there are implications for healing.

Aluminum overload

Patients with end-stage renal disease sometimes receive aluminum-containing antacids to control serum phosphate levels. Absorbed aluminum can be toxic to osteoblasts, leading to the development of osteomalacia.

Dupuytren contracture

Dupuytren contracture is a type of palmar fasciitis that usually affects the fourth and fifth digits. It is most commonly observed in men  of Northern European descent.

Other forms of amyloidosis

Types of amyloidosis to consider in the differential diagnosis of beta-2m amyloidosis include the following:

  • Familial renal amyloidosis
  • Immunoglobulin-related amyloidosis
  • Transthyretin-related amyloidosis
 

Workup

Approach Considerations

The diagnosis of beta-2m amyloidosis is established primarily by its clinical appearance on tissue or bone biopsy.

Obtaining a biopsy of the affected bone or synovium, followed by routine hematoxylin and eosin staining, reveals homogeneous eosinophilic material. Amyloid deposits are positive for Congo red staining, showing green birefringence of the amyloid fibrils under polarized light. Specific immunostaining of amyloid deposits by monoclonal anti ̶ beta-2m antibody confirms the diagnosis of beta-2m amyloidosis.

Antisera to amyloid beta-2m are taken up by the Congo red–positive areas, but are not taken up in other types of amyloidosis. On electron microscopy, typically, 8-10 nm wide, nonbranching, curvilinear fibrils are observed in beta-2m amyloidosis.

The reference range of the serum concentration of beta-2m is 1.5-3 mg/L, while in amyloidosis, serum levels can be elevated to values of 50-100 mg/L. However, an increase in beta-2m levels does not confirm the diagnosis of beta-2 amyloidosis, as these levels are usually elevated with low glomerular filtration rates. Hematologic studies frequently reveal a normochromic, normocytic anemia.

 

Imaging Studies

Radiography

Radiologic lesions typically present prior to the onset of pain. Joint erosions (usually involving large joints), lytic and cystic bone lesions (typically juxta-articular), pathologic fractures (most commonly involving the femoral head), spondyloarthropathies (usually involving the cervical area), and vertebral compression fractures may be observed. However, conventional radiography may underestimate the extent of the disease.[17]

CT scanning

Computed tomography (CT) scans reveal amyloid deposits of intermediate attenuation. CT scans can also be used to identify pseudotumors and pseudocystic areas in the juxta-articular bone. Moreover, CT scanning is the best method for detecting small areas of osteolysis in cortical bone or osseous erosion, and it may be helpful in the assessment of the distribution and extent of destructive changes.[17]

MRI

Magnetic resonance imaging (MRI) shows characteristic long T1 and short T2 relaxation times, resulting in low to intermediate signal intensity. MRI is helpful in differentiating destructive spondyloarthropathies from inflammatory processes and infections. In evaluating amyloidosis, MRI may provide considerably more information than that obtained from conventional radiographic, CT scan, and sonographic studies.[17]

Ultrasonography

Ultrasonography is useful in the detection of tendon thickness. Rotator cuff thickness greater than 8mm, thickening of joint capsules (especially of the hip and knee), and retention of synovial fluid may be observed.

Scintigraphy

Scintigraphy in the diagnosis of beta-2m amyloidosis employs radiolabeled P-component scans, including iodine-123 (123I) serum amyloid P, iodohippurate sodium (131I) beta-2m, and the more natural 111I beta-2m.

The cells surrounding the amyloid deposit take up the circulating tracer, making scintigraphy a useful means of evaluating the total body burden of amyloid. This method has primarily been used in Europe and is not available in North America for diagnosing beta-2m amyloidosis.

PET-FDG scan

Positron emission tomography with fluorodeoxyglucose (PET-FDG), which is able to detect sites of increased inflammatory activity, by detecting the metabolic activity of tissues, measured by glucose uptake, could be a potential tool for early detection of dialysis-related amyloidosis (DRA). A study of 46 dialysis patients with at least one PET scan were compared to a control group of 218 age-matched cases with normal kidney function. PET scans were read in duplicate. Carpal tunnel syndrome was considered a proxy for DRA. A composite “amyloid score” score considered each dialysis year = 1 point; carpal tunnel-DRA = 5 points per site. The prevalence of positive PET was 43.5% in dialysis, 5% in controls (p < 0.0001). PET was positive in 14/15 (93.3%) scans in patients with carpal tunnel. PET sensitivity for detecting DRA was 95% (specificity 64%).[18]  

Biopsy

The criterion standard for diagnosis is histologic identification using Congo red and immunohistochemical staining of biopsy specimens or centrifuged synovial fluid sediments. Puncture biopsies are obtained from cystic bone lesions and intra-articularly in synovia. In contrast to other types of amyloidosis, rectal biopsy and subcutaneous fat aspiration are of little value in diagnosing beta-2m amyloidosis. The most common site from which biopsies are obtained is the sternoclavicular joint.

 

Treatment

Approach Considerations

At present, no adequate treatment of beta-2m amyloidosis exists. Medical therapy is limited to symptomatic approaches to ameliorating joint pain and inflammation. Conservative treatment includes physical and occupational therapy. Wrist splints, cervical collars, lumbar corsets, knee braces, and immobilization for spondyloarthropathies often are helpful.

The treatment of joint pain includes the use of the following:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Intra-articular injections of prednisolone
  • 10% hydrocortisone cream
  • Low-dose oral prednisone in severe cases

Successful reduction of reduction of osteoarticular pain due to dialysis-related beta-2m amyloidosis has been reported with low-dose doxycycline for up to 1 year.[19]

Surgery

Surgical intervention may be effective in alleviating pain and restoring function. Procedures include the following:

  • Carpal tunnel release with surgical decompression of the median nerve or release of the transverse carpal ligaments under endoscopic visualization
  • Flexor tenosynovectomy or percutaneous first annular pulley release
  • Spinal stabilization or laminectomy
  • Total joint replacement

Unfortunately, orthopedic interventions have high failure rates in dialysis-related amyloidosis (DRA) compared with rates in the general population. If, during the course of a surgery, beta-2m amyloidosis is suspected, then a biopsy should be performed at that time.

Apheresis device

In March 2015, the US Food and Drug Administration (FDA) authorized the use of the first device to treat patients with DRA, the Lixelle Beta 2-microglobulin Apheresis Column (Kaneka Corp).  During hemodialysis, the patient's blood passes through the device before entering the dialysis filter, and porous cellulose beads in the device bind to and remove beta 2-microglobin. The FDA granted the device a Humanitarian Use Device designation, which is given if the device diagnoses or treats a disease or condition that affects or is found in fewer than 4000 individuals in the United States each year.[20]

Consultations and follow-up

Involve rheumatologic, surgical, and transplant consultants early. A nephrologist should care for patients with beta-2m amyloidosis on an ongoing basis.

Kidney Transplantation

Kidney transplantation is the treatment of choice for beta-2m amyloidosis. It lowers the blood concentration of beta-2m to the reference range, halting the progression of the disease.

Osteoarticular symptoms, such as joint pain, swelling, and stiffness, disappear within the first week after transplantation. Cystic lesions usually remain unchanged, and regression of amyloid deposits probably does not occur.

Transplantation is not an option for all patients. Some patients on long-term dialysis will have undergone unsuccessful kidney transplantation before they first developed beta-2m amyloidosis; in certain other cases, patients are not suitable candidates.

Prevention

Although preventive measures are hard to assess, possible ways of preventing, or at least decreasing, the incidence of DRA are the use of the following:

  • A high-flux dialyzer
  • Online hemodiafiltration [21]
  • Ultrapure dialysate [22]
  • Adsorbent columns [23]

Guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommend against screening for beta2-microglobulin amyloidosis, including measurement of serum levels of beta2-microglobulin.[24]

High-flux dialyzers

High-flux biocompatible polyacrylonitrile and polysulfone membranes have increased middle molecule removal and have thereby enhanced beta-2m removal during HD and hemofiltration.

Online hemodiafiltration

Online hemodiafiltration has been associated with maximal removal of beta-2m.[21]

Ultrapure dialysate preparations

The use of ultrapure, sterile, and apyrogenic dialysate may aid in decreasing stimulation and in releasing cytokines. It also may decrease plasma levels of acute-phase proteins.[22]

Direct hemoperfusion-type adsorption column (Lixelle)

This was developed to selectively eliminate beta-2m from the circulating blood of patients with DRA. Lixelle treatments reduce the circulating levels of beta-2m and inflammatory cytokines, thereby improving the symptoms of patients with DRA. While this therapy has been used and studied in Japan, it is not currently employed in the United States.[23, 25]

Laser therapy

Studies examining the use of laser-beam irradiation to destroy amyloid fibrils of beta-2m fragments have been performed in Japan. This technique has implications for the prevention of amyloid fibril deposition and for the destruction of preformed amyloid deposits.[26]

 

Medication

Medication Summary

No medical treatment presently exists to reverse or alter the course of beta-2 amyloidosis. Low-dose steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are symptomatic approaches to ameliorating joint pain and inflammation. Medications used include the following:

  • Prednisone - Immunosuppressive agent

  • Triamcinolone - Immunosuppressive agent

  • Capsaicin topical -Topical analgesic

  • Ibuprofen -NSAID

  • Sulindac – NSAID

Immunosuppressants

Class Summary

Used to suppress the inflammatory process.

Prednisone

Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It is used only in severe cases of joint pain and immobility.

Triamcinolone (Aristospan)

Triamcinolone decreases inflammation by suppressing the migration of PMN leukocytes and reducing capillary permeability. The drug decreases autoimmune reactions, possibly by suppressing key components of the immune system.

Analgesics, Topical

Class Summary

Topical analgesics penetrate deep for temporary relief of minor, arthritis-associated aches and pains of muscles and joints.

Capsaicin topical (Capzasin-P, Salonpas-Hot, Zostrix)

Capsaicin is derived from plants of the Solanaceae family. It may render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary

These agents have analgesic, anti-inflammatory properties and antipyretic activities. Their mechanism of action is not known but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Ibuprofen (Advil, Ultraprin, I-Prin, Motrin IB)

Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Sulindac (Clinoril)

Sulindac decreases the activity of cyclo-oxygenase and, in turn, inhibits prostaglandin synthesis. Its action results in the decreased formation of inflammatory mediators.

Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclo-oxygenase (COX), which results in prostaglandin synthesis.

Meloxicam (Mobic)

Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Flurbiprofen

Flurbiprofen may inhibit COX, thereby, in turn, inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

 

Questions & Answers

Overview

What is beta-2-microglobulin (beta-2m) amyloidosis?

What causes beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of dialysis in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of the dialysis membrane in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of diuresis and uremia in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of cytokines in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of advanced glycation end products (AGEs) in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of dialysate in the etiology of beta-2-microglobulin (beta-2m) amyloidosis?

What is the prevalence of beta-2-microglobulin (beta-2m) amyloidosis?

What is the prognosis of beta-2-microglobulin (beta-2m) amyloidosis?

What is the morbidity and mortality associated with beta-2-microglobulin (beta-2m) amyloidosis?

Presentation

Which clinical history findings are characteristic of beta-2-microglobulin (beta-2m) amyloidosis?

Which osteoarticular conditions are associated with beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of carpal tunnel syndrome in beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of flexor tenosynovitis in beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of scapulohumeral arthropathy in beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of spondyloarthropathy in beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of bone cysts in beta-2-microglobulin (beta-2m) amyloidosis?

Which are the signs and symptoms of systemic involvement of beta-2-microglobulin (beta-2m) amyloidosis?

Which GI conditions are associated with beta-2-microglobulin (beta-2m) amyloidosis?

What are the signs and symptoms of cardiac involvement in beta-2-microglobulin (beta-2m) amyloidosis?

Which genitourinary tract conditions are associated with beta-2-microglobulin (beta-2m) amyloidosis?

Which physical findings are characteristic of beta-2-microglobulin (beta-2m) amyloidosis?

What is the clinical staging of beta-2-microglobulin (beta-2m) amyloidosis?

DDX

How is Dupuytren contracture differentiated from beta-2-microglobulin (beta-2m) amyloidosis?

How is secondary hyperparathyroidism differentiated from beta-2-microglobulin (beta-2m) amyloidosis?

How is renal osteodystrophy differentiated from beta-2-microglobulin (beta-2m) amyloidosis?

How is aluminum overload differentiated from beta-2-microglobulin (beta-2m) amyloidosis?

Which types of amyloidosis should be included in the differential diagnoses of beta-2-microglobulin (beta-2m) amyloidosis?

Workup

How is dialysis-related beta-2-microglobulin (beta-2m) amyloidosis diagnosed?

What is the role of radiography in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of CT scanning in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of MRI in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of ultrasonography in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of scintigraphy in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of biopsy in the workup of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

Treatment

How is dialysis-related beta-2-microglobulin (beta-2m) amyloidosis treated?

Which surgical procedures may be beneficial in the treatment of dialysis-related beta-2-microglobulin (beta-2m) amyloidosis?

What is the role of an apheresis device in beta-2-microglobulin (beta-2m) amyloidosis treatment?

Which specialist consultations may be beneficial to patients with beta-2-microglobulin (beta-2m) amyloidosis?

How is beta-2-microglobulin (beta-2m) amyloidosis prevented?

What is the role of online hemodiafiltration in beta-2-microglobulin (beta-2m) amyloidosis prevention?

What is the role of high-flux dialyzers in beta-2-microglobulin (beta-2m) amyloidosis prevention?

What is the role of ultrapure dialysate preparations in beta-2-microglobulin (beta-2m) amyloidosis prevention?

What is the role of direct hemoperfusion-type adsorption column (Lixelle) in beta-2-microglobulin (beta-2m) amyloidosis prevention?

What is the role of laser therapy in beta-2-microglobulin (beta-2m) amyloidosis prevention?

What is the role of kidney transplantation in beta-2-microglobulin (beta-2m) amyloidosis treatment?

Medications

Which medications are used in beta-2-microglobulin (beta-2m) amyloidosis treatment?

Which medications in the drug class Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are used in the treatment of Dialysis-Related Beta-2m Amyloidosis?

Which medications in the drug class Analgesics, Topical are used in the treatment of Dialysis-Related Beta-2m Amyloidosis?

Which medications in the drug class Immunosuppressants are used in the treatment of Dialysis-Related Beta-2m Amyloidosis?