Immunoglobulin light-chain amyloidosis shares genetic susceptibility with multiple myeloma

Amyloid light-chain (AL) amyloidosis is a rare clonal plasma cell disorder with an estimated incidence of 3 per million.1 The disease is characterized by deposition of amyloid fibers derived from immunoglobulin light chains systematically in many organs.2 The symptoms arise in the organs where amyloids accumulate, including the heart, kidney, liver and peripheral nerves; heart failure is the critical life-threatening condition that may ensue in a few months after diagnosis.2 Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic pre-malignant clonal condition, through which all cases of multiple myeloma (MM) pass with a relative risk of 25.3,4 AL amyloidosis, MGUS and MM are hypothesized to be the same disease entity at the cellular level, with AL amyloidosis just being a clonal plasma cell disorder with an ‘unlucky protein’.5 Nevertheless, the genetic etiology of AL amyloidosis is poorly understood. According to a 15-year follow-up study of MGUS patients the relative risk for AL amyloidosis was 8.4.3 Two recent genome-wide association studies (GWAS) of MM have identified seven single-nucleotide polymorphisms (SNPs) that are associated with disease risk, including loci mapping to 2p23.3 (rs6746082), 3p22.1 (rs1052501), 3q26.2 (rs10936599), 6p21.33 (rs2285803), 7p15.3 (rs4487645), 17p11.2 (rs4273077) and 22q13.1 (rs877529).6,7 These seven SNPs also independently influence MGUS risk.8 MM and MGUS are characterized by a high cytogenetic heterogeneity.5,9 The two main pathogenetic groups hyperdiploidy and non-hyperdiploidy can be further subdivided based on the presence of IgH translocations.9 The cytogenetic patterns of AL amyloidosis are similar, but the frequencies of aberrations differ.5 Recently we showed by stratified analyses that the CCND1 c.870G>A splice site polymorphism (rs603965) was strongly associated with the t(11;14)(q13;q32) in MM and MGUS.9 This IgH translocation can only be detected in ~20% of MM and MGUS cases.9 In contrast, it is a common event (53%) in AL amyloidosis.5

In the present study we analyzed the seven MM risk alleles in 443 German AL amyloidosis cases and used published data on German MM and control samples as references. We additionally tested the possible association between rs603965 and the translocation t(11;14) in 329 AL amyloidosis cases with FISH data.

Collection of samples and information from subjects was undertaken with informed consent and approval of the ethical review board of the University of Heidelberg in accordance with the tenets of the Declaration of Helsinki. AL amyloidosis patients were ascertained through the Amyloidosis Center at University Clinic Heidelberg and Department of Internal Medicine, University Clinic Ulm. Blood sample was drawn from newly diagnosed patients. IgM cases were not included. Of 443 patients, 257 were men (58%) and the median age was 61 years (s.d. ±10). The diagnostic criteria used were as described.10 DNA was genotyped using Illumina Human OmniExpress-12 v1.0 arrays. General genotyping quality control assessment was as previously described and all SNPs and samples presented in this study passed the required thresholds.6,7 Fluorescence in situ hybridization (FISH) was performed as previously published.9 Genotype frequencies were compared with recently published genotype data of 1014 German MM patients and 2107 individuals from the German Heinz-Nixdorf Recall study, which had been genotyped using Illumina Human OmniExpress arrays.6,7,9

Table 1 shows genotyping results for the seven SNPs in the newly genotyped AL amyloidosis patients compared to the published data on German MM and controls. The odds ratio of AL amyloidosis associated with each of these SNPs was calculated by unconditional logistic regression. ORs were similar in the two disease groups (Supplementary Figure 1), with only the rs4487645 association showing low heterogeneity between AL amyloidosis and MM (Table 1). The higher effect of rs4487645 in MM may in part be a consequence of a winner’s curse, that is, regression toward the mean implies that by chance the first reported result is higher than the replication result. For AL amyloidosis all risk associations were significant at nominal level <0.05 and rs2285803 was significant even after Bonferroni correction for multiple testing (P<7 × 10−3). These data are consistent with MM and AL amyloidosis showing similarity of the underlying genetic mechanisms.

Table 1 Association results for AL amyloidosis (443 cases and 2107 controls) and multiple myeloma (1014 cases and 2107 controls)

Next, we tested whether the strength of the association was different between AL amyloidosis with <10% vs >10% bone marrow plasma cells (BMPCs), a recently proposed cut point for the differentiation between AL amyloidosis with and without MM11 (Supplementary Table 1). The SNPs rs1052501 at 3p22.1 and rs4273077 at 17p11.2 showed non-significant heterogeneity between the two almost equally large groups. In AL amyloidosis with <10% BMPCs the direction of effect of rs1052501 was the same as that of AL amyloidosis with >10% BMPCs, but the effect size was lower. In this subgroup the risk allele frequency of rs4273077 was similar to controls. Except for rs4273077 the data support our recent result that the risk alleles influence the early stage of clonal plasma cell disorders.8 Nevertheless, due to the low case number definite conclusions about genetic similarity or dissimilarity cannot be drawn.

The functional basis of the seven MM risk associations is not known. Notably, SNPs rs6746082, rs1052501, rs4487645 and rs877529 map to genes or are in linkage with genes that code for proteins interacting with MYC (DNMT3A, CDCA7L, CBX7) or activating MYC transcription (CTNNB1).4 MYC deregulation has been hypothesized to be critical for myeloma pathogenesis.4 SNP rs10936599 is located 5′ to the telomerase RNA component gene (TERC) that together with telomerase reverse transcriptase (TERT) maintains telomere ends.4 According to the genomic annotation, SNP rs2285803 at 6p21.3 localizes to intron 5 of a putative psoriasis susceptibility gene PSORS1C1.7 However, the locus contains many linked genes and is adjacent to the HLA loci.7 Finally, SNP rs4273077 maps to the gene encoding TACI, a receptor for the key MM growth factors BAFF and APRIL.4

Recently we showed by stratified analysis a relationship between CCND1 c.870G>A and risk of t(11;14) MM and MGUS.9 For AL amyloidosis FISH data were available for 329 cases and the t(11;14) was detected in 190 of the patients (58%). SNP rs603965 was also associated with t(11;14) AL amyloidosis, confirming for the first time this translocation-specific effect in a plasma-cell clone. It showed an OR of 1.81 (P=1.5 × 10−7) in the stratified case–control analysis and an OR of 1.51 in the case–case study (P=0.01) (Table 2). The size of effect was comparable in AL amyloidosis with <10% or >10% BMPCs (Supplementary Table 2). As AL amyloidosis with <10% BMPCs is a very early stage of a monoclonal plasma-cell disorder this result supports the hypothesis that the effect of rs603965 arises early in the evolution of a t(11;14) plasma-cell clone.9 However, the molecular basis of the association remains unclear. The risk-associated G allele of rs603965 creates an optimal splice donor site at the exon 4/intron 4 boundary, resulting in the cyclin D1a transcript. The A allele allows read-through into intron 4, resulting in the cyclin D1b transcript.12 Data have shown that cyclin D1a but not cyclin D1b participates in DNA double-stranded repair by binding RAD51.13,14 Recently we have shown that the A allele is associated with non-specific chromosomal aberrations in circulating lymphocytes of healthy donors, indicating that depending on the cell type different effects may be exerted by the CCND1 polymorphism.15

Table 2 Association results for the SNP rs603965 (11q13.3) in AL amyloidosis and multiple myeloma patients with the t(11;14) translocation

In conclusion, these data show similarities in inherited susceptibility between AL amyloidosis and MM. The similarity is extended to equally strong effects of the CCND1 c.870G>A on t(11;14) defined cases.


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Funding was provided to Dietmar-Hopp-Stiftung in Walldorf, The German Ministry of Education and Science (Gliommics 01ZX1309B), the German Cancer Aid no. 110131, GERAMY (BMBF 01GM1107A) and the University Hospital Heidelberg. Additional funding was also provided by the German Ministry of Education and Science and the German Research Council (DFG; Projects SI 236/8-1, SI236/9-1 and ER 155/6-1).

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Correspondence to N Weinhold.

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Supplementary Information accompanies this paper on the Leukemia website

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