Dialysis-related amyloidosis: importance of biocompatibility and age

The histological prevalence of dialysis-related amyloidosis (DRA) is much greater than suspected on clinical grounds: one-third of patients are affected after less than 4 years on haemodialysis (HD) and over 90% after more than 7 years HD. Risk factors include the time on dialysis, the type of HD membrane, and the age of the patient at onset of dialysis. The protective effect of high-flux membranes such as AN69 probably results mainly from the greater clearance of beta2-microglobulin. Other potential but more controversial explanations include a protective influence on residual renal function, a lower stimulation of beta2-microglobulin synthesis or release, or a beneficial influence on advanced glycosylation end (AGE) products. The higher risk of DRA in older patients has recently been suggested to result from an age-related AGE-modification of osteoarticular collagen. The best prevention and treatment of DRA is successful renal transplantation. In patients unsuitable for transplantation, high flux membranes such as AN69 should be used from the start of dialysis. Palliative treatment includes analgesics, low dose prednisone in severe cases, and surgical treatment of complications.