From the Guidelines
Peritoneal dialysis may be a viable option for patients with AL amyloidosis, particularly those with severe cardiomyopathy or hemodynamic instability, as it is well-tolerated and can be performed at home. According to the 2023 ACC expert consensus decision pathway on comprehensive multidisciplinary care for the patient with cardiac amyloidosis 1, peritoneal dialysis is typically performed at home and is available in some outpatient dialysis units, making it a convenient option for patients. Additionally, the same study suggests that peritoneal dialysis may be better tolerated from a hemodynamic standpoint than conventional thrice-weekly hemodialysis for patients with severe cardiomyopathy 1.
The primary concern with peritoneal dialysis in AL amyloidosis patients is the potential for peritoneal membrane dysfunction and complications due to protein deposition in the peritoneal membrane. However, with close monitoring and regular assessments of peritoneal equilibration tests and adequacy measurements, peritoneal dialysis can be a safe and effective option. The role of nephrologists in the multidisciplinary care of patients with amyloidosis is crucial in managing nephrotic syndrome, cardiorenal syndrome, and metabolic complications of chronic kidney disease, as well as in decisions about the need for a kidney biopsy and interpretation of biopsy findings 1.
Key considerations for peritoneal dialysis in AL amyloidosis patients include:
- Close monitoring for signs of peritoneal membrane dysfunction, increased protein loss, or infections
- Regular assessments of peritoneal equilibration tests and adequacy measurements
- Individualized treatment plans taking into account the extent of organ involvement, overall health status, and treatment plan for the underlying disease
- Concurrent management of AL amyloidosis with appropriate chemotherapy regimens to control the production of amyloid proteins and potentially improve organ function.
From the Research
Relationship between AL Amyloidosis and Peritoneal Dialysis
- AL amyloidosis is a systemic disease characterized by amyloid deposition in various organs, including the kidneys, which can lead to renal failure and the need for dialysis 2.
- Peritoneal dialysis (PD) is a valuable treatment option for patients with end-stage renal disease, including those with AL amyloidosis, as it preserves residual renal function and maintains hemodynamic stability 3, 4.
- However, patients with AL amyloidosis may be at increased risk of complications during PD, such as hemoperitoneum and perirenal hematoma, due to the fragile blood vessels associated with the disease 3.
Clinical Outcomes and Predictors
- The clinical outcome of patients with AL amyloidosis affecting the kidney is generally poor, with a median survival of less than 1 year after starting dialysis 5.
- Predictors of poor outcome include high serum creatinine and 24-hour urine protein levels at presentation, as well as the presence of lambda light chain amyloidosis 5.
- In contrast to AA amyloidosis, the effects of AL amyloidosis on survival in peritoneal dialysis patients are not well-studied, but available evidence suggests that PD may be an effective modality for patients with AL amyloidosis and heart failure 4.
Complications and Mortality
- Patients with AL amyloidosis on PD may be at increased risk of mortality due to peritonitis, sepsis, and cardiovascular complications 6.
- The presence of amyloidosis, low initial serum albumin level, and catheter exit site/tunnel infection are independent predictors of poor patient survival on PD 6.
- Further research is needed to fully understand the relationship between AL amyloidosis and peritoneal dialysis, including the potential benefits and risks of PD in this patient population 2, 3, 4, 5.