Multiple myeloma and kidney disease

Abstract

Multiple myeloma (MM) has a high incidence rate in the elderly. Responsiveness to treatments differs considerably among patients because of high heterogeneity of MM. Chronic kidney disease (CKD) is a common clinical feature in MM patients, and treatment-related mortality and morbidity are higher in MM patients with CKD than in patients with normal renal function. Recent advances in diagnostic tests, chemotherapy agents, and dialysis techniques are providing clinicians with novel approaches for the management of MM patients with CKD. Once reversible factors, such as hypercalcemia, have been corrected, the most common cause of severe acute kidney injury (AKI) in MM patients is tubulointerstitial nephropathy, which results from very high circulating concentrations of monoclonal immunoglobulin free light chains (FLC). In the setting of AKI, an early reduction of serum FLC concentration is related to kidney function recovery. The combination of extended high cutoff hemodialysis and chemotherapy results in sustained reductions in serum FLC concentration in the majority of patients and a high rate of independence from dialysis.

Figure 1

International Myeloma Working Group definition of multiple myeloma [9]. *MM-related organ damage includes the following: hypercalcemia [serum calcium > 0.25 mmol/L (1 mg/dL) above normal]; renal insufficiency (serum creatinine > 1.0 mg/dL above base line); anemia (hemoglobin > 2 g/dL below baseline); bone, lytic lesions, or osteoporosis with compression fracture; and symptomatic hyperviscosity, amyloidosis, or recurrent bacterial infections (>2 in 12 months). BMPC = bone marrow plasma cells.

Figure 2

Acute kidney injury and progression to CKD [19]. (a) Conceptual model of acute kidney injury (AKI). (b) Natural history of AKI. Patients who develop AKI may experience (1) complete recovery of renal function, (2) development of progressive chronic kidney disease (CKD), (3) exacerbation of the rate of progression of preexisting CKD, or (4) irreversible loss of kidney function and evolve into ESRD.

Figure 3

Guide to frequency of monitoring by GFR and albuminuria categories [33]. This GFR and albuminuria grid reflects the risk for progression by intensity. The numbers in the boxes are a guide to the frequency of monitoring (number of times per year). ACR = albumin – creatinine ratio; CKD = chronic kidney disease; GFR = glomerular filtration rate.