Avoiding a Pain in the Neck: Dialysis-Related Amyloidosis

The longer you are on dialysis, the greater the odds that you may develop dialysis-related amyloidosis (DRA). What is DRA? Beta-2 microglobulin ( B2M ), a protein, forms into long strands. These strands, or fibrils, are called amyloid. They build up in joints, bones, and soft tissues—where they can cause pain and damage. Better equipment makes DRA less likely today than in the past. And, there are steps you can take now to reduce your risk down the road.

Causes of DRA

B2M Fibril It is normal to have B2M in your body. In fact, B2M is found on the surface of most of your cells. Healthy kidneys remove excess B2M that builds up when your cells break down. 1 Failed kidneys can't remove B2M , so you have to rely on dialysis or transplant.

DRA occurs when B2M forms into fibrils. A number of factors can trigger the forming of fibrils, like:

A pain in the neck Another key reason that amyloid fibrils form is oxidative stress. This is damage that occurs when cells react with oxygen. It's quite a bit like rust! This type of stress on your body is more likely if you:

One type of oxidative stress is due to advanced glycation end products, or AGEs. AGEs form when sugar reacts with protein or fat. You can see AGEs in "browned" foods like coffee beans, roasted meats, and baked goods. (Your body absorbs about 30% of the AGEs in foods you eat.7) AGEs also form in your body, and in higher levels if you have diabetes. AGEs damage blood vessels and nerves.

Carpal Tunnel Syndrome It takes many years—often 10 to 20—for amyloid to cause symptoms in people on dialysis. For reasons doctors don't yet know, B2M fibrils tend to attack joints and bones. In the spine, the problem first appears in the discs of the neck, then in the middle discs, and last in the lower back. 8

Joints that move more may be more prone to amyloid. 8 This may be why hands and wrists are so often affected. Carpal tunnel syndrome occurs when nerves for the hand are squashed in a too-small tunnel of bone. This leads to pain and numbness. One study found more carpal tunnel syndrome in access than non-access arms. 9 Another found that 2/3 of carpal tunnel syndrome in people on dialysis was due to amyloid. 10 "Trigger finger", a problem where a thumb or finger can get stuck in a bent position, can also be due to amyloid.

Bones are a second major target for amyloid damage. At any given moment, tiny spots of your bones are being remodeled—broken down and rebuilt. Osteoclast cells break down old bone so it can be fixed and made stronger. In mice, B2M brought more osteoclast cells to bone to break them down. 11 Amyloid can cause painful bone cysts and fractures. Like wrists, shoulders can be affected, too. 12

Bone cyst Rarely, amyloid can harm soft tissues. Researchers have found amyloid in the heart, 13,14 the buttocks, 15 the gut (causing pain and bleeding), 16,17 and even the tongue. In the tongue, amyloid can affect both taste and speech. 18

Prevention and treatment of DRA

It's best not to get DRA. How can you avoid it? The causes give you some clues. While none of us can avoid aging, you can:

If you have DRA, the symptoms can be treated. Surgery can help ease carpal tunnel syndrome and trigger finger. A kidney transplant can help reduce pain quite quickly—in as little as a week, though the bone cysts and damage don't go away. 24 In the future, other treatment options may come forward. Much of the research done on DRA is from Japan. There, people on HD can have their blood passed through Lixelle, a column that removes B2M . Studies have found that Lixelle helps joint stiffness and pain, and prevents bone cysts compared to standard HD. 25

Lasers Lasers have also been used to break up B2M fibrils. This may one day help to keep fibrils from forming and to treat them once they have formed. 26 This research was also done in Japan.

Finally, a new study from Greece uses magnets to reduce B2M levels in the blood of people on HD. Before an HD treatment, magnet nanoparticles are given by IV. A magnetic dialyzer is used to pull the tiny magnets back out of the blood. Since B2M is attracted to the magnets, the HD treatment pulls B2M out, too. 27


DRA can cause pain and damage to bones, joints, and tissues. But advances in HD have made the problem less common. You can take steps today to reduce your risk of DRA later.


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