ASH 2026 guidelines: Diagnosis of AL amyloidosis

The American Society of Hematology (ASH) 2026 guidelines on the diagnosis of light chain (AL) amyloidosis were published in Blood Advances by Kukreti et al. A multidisciplinary panel developed 12 evidence-based recommendations to support timely and accurate diagnosis of AL amyloidosis. 

Key data: Initial evaluation should include serum and urine immunofixation plus serum free light chain (sFLC) testing to detect monoclonal gammopathy. Diagnosis requires tissue confirmation with validated amyloid subtyping. Surrogate sampling with abdominal fat pad aspiration and bone marrow biopsy is recommended when appropriate, reserving organ-specific biopsy for non-diagnostic or infeasible cases. Bone scintigraphy should not be used to diagnose AL cardiac amyloidosis in patients with detectable monoclonal protein; however, it is recommended for diagnosing transthyretin cardiac amyloidosis when a plasma cell disorder has been excluded. Cardiac biomarker testing and imaging are recommended to assess organ involvement. 

Key learning: Early recognition of AL amyloidosis requires prompt screening, tissue confirmation with validated subtyping, and organ assessment to prevent diagnostic delays and improve outcomes.