# Amyloidosis: Type the Protein Before Treating

Assess cardiac risk, kidney trajectory, blood pressure, neuropathy, and treatment tolerance. Hematologic response and organ response may occur on different timelines.

![Infographic: Amyloidosis: Type the Protein Before Treating](https://urinenephrology.org/visual-reference/images/mastery-amyloid-typing.png?v=20261003c)

## Deposition is a pattern

Amyloid can involve kidneys, heart, nerves, and other tissues. Identifying deposits is only part of the diagnosis; the precursor protein determines treatment.

## Recognize discordant clues

Proteinuria, restrictive cardiac features, autonomic symptoms, and a monoclonal protein can appear in different combinations. Absence of nephrotic proteinuria does not exclude systemic disease.

## Order the complete monoclonal screen

Use serum free light chains plus serum immunofixation and urine immunofixation. Electrophoresis alone is not an adequate exclusion test. Interpret light-chain concentrations and ratio with kidney function; impaired clearance can elevate both chains.

## Distinguish association from cause

MGUS can coexist with unrelated amyloidosis. A monoclonal protein or abnormal light-chain ratio alone does not establish AL amyloid as the tissue type.

## Type deposits before clone-directed therapy

Congo-red-positive tissue establishes amyloid deposition, not its precursor. A coincidental monoclonal gammopathy does not prove AL. When type is uncertain, request validated tissue typing, including mass spectrometry when available, and reconcile the result with the monoclonal screen.

## Watch organs, not only protein

Assess cardiac risk, kidney trajectory, blood pressure, neuropathy, and treatment tolerance. Hematologic response and organ response may occur on different timelines.

## Supporting evidence

- [Supporting guideline or source](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2023/01/19/14/49/2023-acc-consensus-on-cardiac-amyloidosis)

## Source lessons

- [monoclonal protein interpretation](https://urinenephrology.org/mastery/amyloid-series/monoclonal-protein-interpretation.html)
- [al amyloidosis myeloma review](https://urinenephrology.org/mastery/glomerular/al-amyloidosis-myeloma-review.html)
- [mgus myeloma mass fix](https://urinenephrology.org/mastery/glomerular/mgus-myeloma-mass-fix.html)
- [renal amyloidosis review](https://urinenephrology.org/mastery/glomerular/renal-amyloidosis-review.html)
- [al amyloidosis myeloma](https://urinenephrology.org/mastery/paraprotein/al-amyloidosis-myeloma.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.