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AL amyloidosis is caused by a clone of plasma cell. Due to the impact of the disease on patient survival, careful evaluation of organ involvement is essential and treatment should be tailored to single patient's risk. AIM: We analyzed the clinical, laboratory and histological characteristics of 21 elderly patients (pts) (mean age 74.7 ± 7.97 years, range 55–81) with AL amyloidosis, including 17 patients (81%) with biopsy-proven renal involvement, who were ineligible for bone marrow transplantation, and evaluated the impact of renal impairment on survival. Cardiac and renal involvement was found in 14 (67%) cases. Among the 17 patients with renal involvement, 12 had renal failure with proteinuria, and one showed isolated renal failure and vascular amyloid deposition. Hematological response occurred in 57.1% after first line therapy (75% after three cycles). In six of the patients with renal involvement, proteinuria decreased from 4.2 to 1.1 g/24 h (range 0.2–3 g/24 h), serum Creatinina (sCr) levels declined or stabilized. Severe renal failure at diagnosis was found to directly influence patient survival, while the Staging System for Renal Outcome in AL Amyloidosis did not associate with outcomes. To the best of our knowledge this is the first case series in which the whole cohort of patients with urinary or functional abnormalities underwent a histological evaluation. None of the patients were eligible for bone marrow transplantation. Hematologic response was 57.1%, while renal response was much lower (35%). Of note, the Staging System did not completely apply to this peculiar setting of patients in whom renal involvement was not presumptive but biopsy-proven. More aggressive approaches may be needed in these patients to avoid the inexorable progression of the disease.

Background and Aims: Many patients with End Stage Kidney Disease do not undergo percutaneous kidney biopsy (KB) and do lack a definite diagnosis. Whether KB is beneficial in the extreme patients’ categories, i.e., age >75 years and very late referrals with kidney disease requiring renal replacement therapy at the first evaluation, remains controversial. Aim: To analyse the benefit/risk balance in terms of therapeutic options and general outcome of KB procedure in these borderline categories. Method Files for all biopsies performed in our Centre between 2013 and 2019 (# 903 inpatients’ native kidney) were retrospectively analysed with special focus on histological diagnosis, biopsy complications, and post-biopsy patient’s outcome. Two groups of high risk patients were identified 1. >75 years old patients, and 2. patients requiring dialysis at the first clinical evaluation. A rigorous protocol of screening of the bleeding risks was adopted. Results Of the 903 biopsies, 217 cases (24%) had group 1, and 92 (10%) group 2 criteria. Group 1: mean age 80 years (range 75-92), main histological diagnoses: ANCA associated vasculitis (AAV) (12,4%); membranous nephropathy (MN) (11,5%), diabetic nephropathy (10,1%), IgA glomerulonephritis (IgAGN) (9,2%), cast nephropathy (9,2%), renal amyloidosis (9.2%), focal segmental glomerulosclerosis (FSGS - 7,8 %). Group 2: mean age 60 years (range 20-92), most frequent histological diagnosis: AAV (26,1%); cast nephropathy (19,6 %), nephroangiosclerosis (9,8%), IgAGN (7,6 %), diabetic nephropathy (6,5%), renal amyloidosis (5,4%); FSGS (4,3%). Five major complications (2,3%), including AV fistula with spontaneous resolution in 4 patients and 1 case of severe bleeding requiring arterial embolization, and 14 minor complications (6,5%), including post biopsy haematomas Conclusion Given its high diagnostic value (especially in patients who are willing to be transplanted), the prognostic significance (and the assessment of the extent of the renal sclerotic changes), and the potential impact on the treatment policy, indications to percutaneous kidney biopsy in elderly and dialysis patients should be probably revised.