Case 7: Dialysis Related Amyloidosis

“Ouch my wrist hurts.” Your nephrologist may be able to help.

You see an 82 year old African American male with history of ESRD secondary to polycystic kidney disease, who has been on hemodialysis for the last 12 years via a left brachiocephalic AVF. He is otherwise in surprisingly good health and very functional. While you are rounding in the dialysis unit, he tells you that he has been having left shoulder and left wrist pain and was told that he may have carpal tunnel syndrome in his left wrist. You are concerned that he may be developing dialysis related amyloidosis.
This is correct!

Dialysis related amyloidosis is caused by tissue accumulation of β2 microglobulin (in synovia, bones, and rarely visceral organs) in patients with renal failure who typically have a long dialysis vintage (more than 8-10 years). Carpal tunnel syndrome is one of its manifestations. With the use of modern high flux dialyzers, the prevalence of dialysis related amyloidosis has declined considerably, however it can still be seen as the endogenous production of β2 microglobulin far exceeds its removal even with modern dialysis. There is also a significant rebound in plasma levels of β2 microglobulin post dialysis. Therefore increasing dialysis treatment time such as with daily nocturnal dialysis as well as using a high flux dialyzer to improve convective clearance of β2 microglobulin helps this condition (Choice 3). Changing to a high efficiency dialyzer with a high KoA (Choice 2) would not help, as β2 microglobulin has a low diffusive clearance. Ligating AVF (Choice 4) is sometimes used as treatment for steal syndrome which this patient does not have. Increasing dialysate flow (Choice 1) will not help β2 microglobulin clearance.

This is incorrect. Try again.