Dialysis-related Amyloidosis - a pain in the...

...shoulder, wrists and other places.

For the last few years, I have pain in my right shoulder during dialysis (I dialyse through the night, 5 nights a week). The pain is bad when it is cold in the room (during winters and when the AC is on at night during summers). The last one week was particularly bad as it was colder than usual in Hyderabad.

An MRI diagnosed it as Amyloid Arthropathy. My nephrologist said Amyloid-related problems are common in long-term dialysis patients. Amyloid is a small, thin fibre consisting of Beta 2 - Microglobulin (Beta2-m). Beta2-m is a large-sized molecule that does not get removed completely during dialysis. So, over time, it starts building up in the body and forms Amyloid which gets deposited in various places like the wrist, shoulders etc.

I have already had surgery for Carpal Tunnel Syndrome in both my wrists a few years back.

I wondered why I had a problem with Amyloid as Daily Nocturnal Home Hemodialysis (DNHHD) is supposed to remove Beta2-m more efficiently than conventional HD (thrice a week, four-hours each time). My doctor said while DNHHD does a much better job of removing Beta2-m, it still does not remove it fully. 

The only way Beta2-m can be removed fully is when you have a healthy kidney (either native kidneys or after a kidney transplant).

Among the various modalities of dialysis, some studies have shown the following retention of Beta2-m per year in an individual whose weight is 70 kg and whose kidney function is 0:

Type of Dialysis	Retention of Beta2-m (grams/year)
Low Flux HD	111
High Flux HD	97
Short Daily HD	77
Daily Nocturnal HD	53
Short Daily HDF	51

So, even with what may be considered the gold standard in Hemodialysis today, an individual still has significant amounts of Beta2-m retained every year. High Flux dialysers, increased weekly hours of dialysis and Hemodiafiltration are all better in removing Beta2-m, thus reducing the risk of developing Amyloid deposits.

There have been some new developments in this field. A Beta2-m adsorption column is used in series with the dialyser during dialysis. This has shown promising results. Special dialysers that are also supposed to be better at removing Beta2-m have recently been introduced.

All these therapies will still have limitations and I doubt if all the Beta2-m will ever be removed. The best  solution is a Kidney Transplant.

Until that is possible, we should get as much dialysis as practically possible, with a better dialyser and Hemodiafiltration if possible (one session per week of HDF and the others being HD is also a good start). This should help reduce the build-up of Beta2-m and hopefully delay the symptoms.