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AA amyloidosis is an unrecognised problem among people who inject drugs
Liz Highleyman, 2017-05-16 07:30:00
AA amyloidosis, a condition resulting from skin and
soft tissue infections that can lead to kidney failure, may be more common than
previously recognised among people who inject drugs, according to a
presentation yesterday at the 25th Harm Reduction International Conference (HR17) in
While this form of amyloidosis is not treatable, it
can be prevented by prompt care of abscesses due to drug injection, said
Magdalena Harris of the London School of Hygiene and Tropical Medicine.
Amyloidosis occurs when abnormal proteins known as amyloid fibrils build up in body tissues. The AA type of amyloidosis is
cause by chronic inflammation. These proteins are usually soluble, but in about
10% of people sustained high levels of serum amyloid can result in deposits in
organs such as the kidneys, liver, and spleen.
The kidneys are usually affected first, according to
Harris. Symptoms of AA amyloidosis kidney disease include proteinuria (protein
in the urine) and swelling of the extremities. Over time it can lead to renal failure, the need for
dialysis, kidney transplantation or death. The condition is diagnosed by kidney
biopsy or an test known as a serum
amyloid P or SAP scan.
Some people who inject drugs resort to subcutaneous
injection, or 'skin popping', especially if they cannot access their veins, which
can result in cellulitis. Untreated skin and soft tissue infections can cause
persistent on-going inflammation that can trigger AA amyloidosis.
In the UK up to 60% of people who inject drugs report
recent skin and soft tissue infections, and about 10%
- or 20,000 individuals - are hospitalised for this reason each year. UK drug
treatment services have seen a growing number of clients with AA amyloidosis or
on kidney dialysis in recent years, Harris said.
Harris and colleagues conducted a systematic review to
assess AA amyloidosis as a serious consequence of skin and
soft tissue infections in people who inject drugs. Looking at six
databases, they identified 30 relevant published studies, mostly case reports
or case series. Of these, 18 were from the US, six from the UK and the rest
All these reports were published in nephrology, hepatology,
pathology or other specialised medical journals and none appeared in drug
addiction or harm reduction publications, explaining why the problem is
under-recognised in the addiction and harm reduction community, Harris said.
AA amyloidosis was first reported among injection drug
users in 1970s. Later that decade the condition was linked to skin and
soft tissue infections, and informally dubbed 'skin popper's disease'. The
first cases in Europe were reported in the late 1980s.
Incidence had since increased over the past decade, and
AA amyloidosis has become the main cause of progressive kidney disease among injection
drug users. A Norwegian study found that 75% of all renal disease among
injection drug users was due to AA amyloidosis, while a study from Romania
found it to be the involved in 23% of all deaths among people who inject drugs.
The prevalence of HIV and hepatitis C virus (HCV)
infection are high among injection drug users with AA amyloidosis, reaching 95%
in one UK study and 100% in a US study. HIV-related immune
suppression and chronic inflammation may play a role -- for
instance, soft tissue infections may take longer to heal. But the link could
also be related to the affected population having more risk practices and less
access to care and facilities such as showers, Harris said.
Injection drug users who develop AA amyloidosis are
usually diagnosed late, they may have difficulty undergoing dialysis due to
damaged veins, and death from sepsis is common. These individuals have high
mortality, typically dying within two years.
The authors of one
study noted that AA amyloidosis is "preventable and
potentially reversible" if the inflammatory stimulus is removed, stressing
that "early attention to skin and soft tissue infection is crucial."
Harris and colleagues are now conducting the first study
looking at ways to improve prevention and care of skin and soft tissue
infections and assessing the feasibility of AA amyloidosis screening and
referral for treatment.
Now that the literature review has outlined the
problem, the researchers will next conduct a urine screening and risk factor survey
of 400 people at five drug treatment centres in the UK. A later phase will
explore skin and soft tissue infection prevention and risk management,
interviewing people who inject drugs to determine what they need.
emphasised the need to reach people who inject drugs where they are, providing
education, care of skin and soft tissue injuries on the streets and perhaps
take-home wound care kits.
Although screening for AA amyloidosis is cheap, it is
still uncertain whether its prevalence is high enough to recommend screening
for all people who inject drugs, Harris said.