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Dialysis-Related Amyloidosis Revisited

¹ Department of Radiology, Waid Hospital, Zürich, Switzerland 8037.
² Department of Nephrology, Waid Hospital, Zürich, Switzerland 8037.
³ Department of Radiology, Balgrist University Hospital, Zürich, Switzerland 8008.
⁴ Department of Radiology, Medical University Innsbruck, Anichstrasse 35, Innsbruck Tyrol, Austria 6020.

View larger version (125K): [in a new window]   Fig. 1 —66-year-old woman on hemodialysis for 10 years for analgesic nephropathy with biopsy-proven dialysis-related amyloidosis. Axial radiograph of left hip shows well-defined cystic lesion (arrow) with sclerotic rim in area of left femoral neck. Femoral lesions arise in subcapital region, usually commencing at superolateral aspect of femoral neck. The most characteristic cysts secondary to amyloidosis occur in acetabula and proximal femurs. Because of pathologic fracture, surgical repair had to be performed on patient 1 year later.

View larger version (156K): [in a new window]   Fig. 2A —52-year-old woman on hemodialysis for 26 years for lupus nephritis with biopsy-proven dialysis-related amyloidosis. Conventional radiograph shows discrete erosion in lateral aspect of acetabulum (arrowhead). No other abnormalities are visible.

View larger version (184K): [in a new window]   Fig. 2B —52-year-old woman on hemodialysis for 26 years for lupus nephritis with biopsy-proven dialysis-related amyloidosis. Coronal T1-weighted MR image (TR/TE, 500/14) reconfirms erosion (arrowhead), which is much more obvious than in conventional radiograph. Large intraarticular and periarticular hypointense amyloid deposits (arrows) are also evident. Amyloid deposits show intermediate to low intensity in T1 sequence.

View larger version (188K): [in a new window]   Fig. 2C —52-year-old woman on hemodialysis for 26 years for lupus nephritis with biopsy-proven dialysis-related amyloidosis. Corresponding T2-weighted MR image (5,000/122) shows that amyloid deposits (arrows) seen in B have low to intermediate signal intensity on T2-weighted image.

View larger version (186K): [in a new window]   Fig. 2D —52-year-old woman on hemodialysis for 26 years for lupus nephritis with biopsy-proven dialysis-related amyloidosis. Axial T1-weighted fat-suppressed MR image (768/14) after administration of contrast material shows only mild peripheral enhancement (arrowheads), which is characteristic of amyloidosis.

View larger version (127K): [in a new window]   Fig. 3A —57-year-old man on hemodialysis for 23 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Conventional radiograph shows radiolucent lesions of various sizes involving carpal bones (arrows). Most have sclerotic margins and some have a lobulated outline. In carpi, lunate and scaphoid are most often affected.

View larger version (149K): [in a new window]   Fig. 3B —57-year-old man on hemodialysis for 23 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Longitudinal sonography exhibits thickening of flexor tendon and amyloid tissue in synovial tissue adjacent to tendon (arrows).

View larger version (123K): [in a new window]   Fig. 3C —57-year-old man on hemodialysis for 23 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sagittal T1-weighted MR image (595/20) shows erosions involving lunate bone (solid straight arrows). Low-signal-intensity tissue representing amyloid is evident within lesion. Amyloid deposits encasing flexor (open arrow) and extensor (curved arrow) tendons are also visible. Marked thickening of flexor tendons caused by amyloid tissue (arrowheads) is evident.

View larger version (141K): [in a new window]   Fig. 3D —57-year-old man on hemodialysis for 23 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Axial intermediate-weighted fat-suppressed MR image (2,430/30) shows marked thickening of flexor (straight arrows) tendons. Tendons are encased in amyloid tissue (curved arrows). Erosions involving carpal bones (arrowheads) are also visible.

View larger version (160K): [in a new window]   Fig. 3E —57-year-old man on hemodialysis for 23 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Coronal T1-weighted image (372/20) shows encasement of carpal bones with amyloid tissue (arrows). Multiple erosions (arrowheads) are also obvious.

View larger version (127K): [in a new window]   Fig. 4A —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Conventional radiograph shows well-defined cystic lesion (arrowhead) with sclerotic rim (arrows) in superior-posterior left humeral head. Humeral lesions generally occur around anatomic neck of humerus and in relation to bicipital groove.

View larger version (151K): [in a new window]   Fig. 4B —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Longitudinal sonogram of left shoulder shows erosion of humeral head (straight arrows), which communicates with joint space. Erosion is filled with echogenic amyloid tissue (curved arrows).

View larger version (158K): [in a new window]   Fig. 4C —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sonogram of right subdeltoid bursa shows polypoidlike synovial thickening (arrows) and large anechoic synovial effusion.

View larger version (180K): [in a new window]   Fig. 4D —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Coronal T1-weighted MR image (470/12) shows osteolysis in superior-posterior humeral head, which communicates with joint (arrow). Low-signal-intensity tissue representing amyloid appears within lesion. Amyloid deposits are also visible within subdeltoid bursa between deltoid muscle and humerus (arrowheads).

View larger version (190K): [in a new window]   Fig. 4E —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Corresponding T2-weighted MR image (3,000/91) of same lesions. Signal of amyloid tissue (straight arrows) remains low with exception of small rim of high intensity around intraosseous lesion (arrowheads). These findings are characteristic for amyloidosis. Complete rupture of supraspinatus tendon (curved arrow) is apparent.

View larger version (177K): [in a new window]   Fig. 4F —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Axial T2-weighted MR image (1,250/26) of atlantoaxial joint shows pseudotumoral mass of periodontoid soft tissue (arrowheads) bulging into anterior subarachnoid space and resembling rheumatoid pannus. Pseudotumors are observed at site of synovial or ligamentous structures, namely, atlantoaxial joint synovium and transverse ligament.

View larger version (127K): [in a new window]   Fig. 4G —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sagittal T2-weighted MR image (4,280/121) of cervical spine shows pseudotumor (straight arrow) encasing odontoid process. Lesion shows low signal intensity. Erosion in anterior aspect of odontoid process (white arrowhead) is also present. Erosive spondyloarthropathy with anterolisthesis of body of C3 on C4 is obvious in intervertebral level C3/C4 (curved arrow). Low signal in T2-weighted images is present, which allows exclusion of infection. Note also amyloid deposits (black arrowheads) at site of dorsal ligament structures.

View larger version (127K): [in a new window]   Fig. 4H —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Axial CT scan (bone window settings) of atlantoaxial joint shows erosions and resorption of odontoid process (arrowhead) and body of C2 (arrows) due to pseudotumoral mass of periodontoid soft tissue.

View larger version (137K): [in a new window]   Fig. 4I —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sagittal T2-weighted MR image (5,000/131) of thoracic spine shows marked destruction of disk space T8-9 with irregularity of adjacent endplates, multiple erosions, and reactive sclerosis (arrow). Only a little fluid appears within disk space. Hypointense amyloid tissue is obvious in area of right facet joints (black arrowhead) and at site of dorsal ligament structures (white arrowhead).

View larger version (170K): [in a new window]   Fig. 4J —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Axial T2-weighted MR image (4,500/150) at level of T8-9 shows hypointense amyloid tissue at site of synovial and ligamentous structures of right facet joint infiltrating in epidural space and right neuroforamen (arrowhead). Amyloid deposits (arrows) also appear at site of dorsal ligament structures.

View larger version (132K): [in a new window]   Fig. 4K —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sagittal T2-weighted MR image (5,000/122) of lumbar spine shows hypointense amyloid tissue at site of synovial and ligamentous structures of right facet joints of T12 through L5 (arrows). Amyloid deposits also appear at site of dorsal ligament structures (arrowheads).

View larger version (161K): [in a new window]   Fig. 4L —63-year-old man on hemodialysis for 31 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Sagittal CT scan reconstruction of upper lumbar spine shows multiple erosions in superior and inferior articular process of facet joints (arrows) caused by amyloid deposits.

View larger version (78K): [in a new window]   Fig. 5A —59-year-old woman on hemodialysis for 15 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Lateral radiograph of cervical spine shows erosive spondyloarthropathy from C2 through C7 intervertebral levels, with narrowing of intervertebral disk space and extensive erosion and reactive sclerosis of adjacent vertebral endplates. Segments C2 through C5 are particularly affected. No relevant osteophytosis is evident; 10-mm anterolisthesis of body of C2 on C3 (black curved arrow) and 5-mm anterolisthesis of body of C3 on C4 (white curved arrow) are apparent. Resorption of C3 and C4 anterior margins (straight arrows) is also shown, a finding similar to that of infectious spondylodiscitis.

View larger version (95K): [in a new window]   Fig. 5B —59-year-old woman on hemodialysis for 15 years for chronic glomerulonephritis with biopsy-proven dialysis-related amyloidosis. Lateral radiograph of cervical spine obtained 2 years later shows severe progression of disease with progressive narrowing of intervertebral spaces from C2 through C7 (arrowheads). In patients with destructive spondyloarthropathy who are undergoing hemodialysis, radiographic progression of abnormalities is often rapid—that is, over a period of months.

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