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Attias P, Moktefi A, Matignon M, Dupuis J, Debiais-Delpech C, Grimbert P, Lang P, Audard V. Monotypic plasma cell interstitial nephritis as the only clinical manifestation in a patient with previously undiagnosed indolent multiple myeloma: A case report. Medicine (Baltimore) 2016; 95:e4391. [PMID: 27495052 PMCID: PMC4979806 DOI: 10.1097/md.0000000000004391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Predominantly monotypic plasma cell infiltrates are an uncommon renal finding in patients with malignant lymphoplasmacytic proliferation. CASE PRESENTATION We report the case of a 52-year-old man with chronic kidney disease and significant proteinuria associated with a monoclonal immunoglobulin spike (IgGκ). Kidney biopsy revealed the presence of atypical multinucleated CD138 plasma cells with voluminous nuclei stained exclusively with a κ antibody. Electron microscopy showed mesangial and segmental parietal electron-dense, nonorganized hyaline deposits without immunogold labeling for the κ light chain. The bone marrow aspirate revealed 6% of apparently mature plasmocytes without dystrophy. We therefore concluded that the patient had an indolent multiple myeloma with specific renal involvement in the form of malignant monotypic interstitial plasmacytic infiltration. We initiated a specific chemotherapy regimen including bortezomib-cyclophosphamide-dexamethasone. After 4 months of follow-up, creatinine levels had improved slightly and free κ light-chain levels had decreased significantly within the normal range. CONCLUSION This case highlights the need to consider neoplastic interstitial plasma cell infiltration systematically in patients diagnosed with an apparently benign monoclonal gammopathy and to consider adaptation of the chemotherapy regimen, to improve renal function.
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Affiliation(s)
- Philippe Attias
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie et Transplantation, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Groupe Hospitalier Henri–Mondor/Albert-Chenevier
| | - Anissa Moktefi
- AP-HP, Département de Pathologie, Groupe Hospitalier Henri-Mondor/Albert-Chenevier
- Université Paris-Est-Créteil (UPEC), Département Hospitalo-Universitaire (DHU) Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, INSERM U 955
| | - Marie Matignon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie et Transplantation, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Groupe Hospitalier Henri–Mondor/Albert-Chenevier
- Université Paris-Est-Créteil (UPEC), Département Hospitalo-Universitaire (DHU) Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, INSERM U 955
| | - Jehan Dupuis
- AP-HP, Unité d’Hémopathies Lymphoïdes, Groupe Hospitalier Henri-Mondor/Albert-Chenevier
- UPEC, DHU VIC, IMRB, Equipe 9, INSERM U 955, Créteil
| | - Céline Debiais-Delpech
- Centre de Référence des Amyloses Primitives et des Maladies de Dépôts d’Immunoglobulines Monoclonales
- Département de Pathologie, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Philippe Grimbert
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie et Transplantation, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Groupe Hospitalier Henri–Mondor/Albert-Chenevier
- Université Paris-Est-Créteil (UPEC), Département Hospitalo-Universitaire (DHU) Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, INSERM U 955
| | - Philippe Lang
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie et Transplantation, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Groupe Hospitalier Henri–Mondor/Albert-Chenevier
- Université Paris-Est-Créteil (UPEC), Département Hospitalo-Universitaire (DHU) Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, INSERM U 955
| | - Vincent Audard
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Néphrologie et Transplantation, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Groupe Hospitalier Henri–Mondor/Albert-Chenevier
- Université Paris-Est-Créteil (UPEC), Département Hospitalo-Universitaire (DHU) Virus-Immunité-Cancer (VIC), Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, INSERM U 955
- Correspondence: Vincent Audard, Service de Néphrologie et Transplantation, Groupe Hospitalier Henri-Mondor/Albert-Chenevier, 51, Avenue du Marechal-de-Lattre-de-Tassigny, 94010 Créteil Cedex, France (e-mail: )
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Curti A, Schwarz A, Trachsler J, Tomonaga Y, Ambühl PM. Therapeutic Efficacy and Cost Effectiveness of High Cut-Off Dialyzers Compared to Conventional Dialysis in Patients with Cast Nephropathy. PLoS One 2016; 11:e0159942. [PMID: 27467401 PMCID: PMC4965060 DOI: 10.1371/journal.pone.0159942] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High Cut-Off (HCO) dialysis membranes efficiently reduce serum free light chain (FLC) concentrations and may improve renal recovery and survival from multiple myeloma (MM) associated renal failure with cast nephropathy. However, clinical trials comparing dialysis with HCO versus conventional filters are lacking. The aim of this study was to assess clinical outcomes and economic impact of HCO dialyzers compared to conventional hemodialysis membranes in cast nephropathy. METHODS Multicenter retrospective analysis of 19 patients treated for renal failure from FLC associated cast nephropathy with standard induction chemotherapy (bortezomib/dexamethasone). We compared hemodialysis treatment with High Cut-Off (n = 12) versus conventional dialyzers (n = 7). Primary endpoint was survival; secondary endpoints were renal recovery, renal function and treatment costs. RESULTS At 12 months, patient survival was 25% in the HCO group versus 0% in controls (p = NS). A tendency towards faster renal recovery (p = 0.066) and better renal function at 3, 6 and 12 months (p = 0.109) after diagnosis of MM was noted in the HCO group. Complete renal response rate was achieved in 10.5 and 0% of HCO and control patients, respectively, partial renal response in 15.8 and 5.3%, and minor renal response in 26.3 and 15.8%, respectively. Both patient survival and renal recovery were significantly correlated with the extent of free light chain (FLC) reduction in serum. Median treatment costs were CHF 230'000 and 223'000 (p = NS) in the HCO and control group, respectively. CONCLUSIONS Hemodialysis treatment with HCO membranes for cast nephropathy tended towards better survival as well as faster and better recovery of renal function versus conventional dialyzers. Moreover, total medical costs were comparable between groups. In the absence of results from randomized prospective trials on this topic, the use of HCO dialyzers in patients with renal failure from cast nephropathy may be recommended. Prospective randomized trials are required.
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Affiliation(s)
- Adriano Curti
- Renal Division, Stadtspital Waid Zurich, Zurich, Switzerland
| | - Albin Schwarz
- Renal Division, Stadtspital Waid Zurich, Zurich, Switzerland
| | | | - Yuki Tomonaga
- Epidemiology, Biostatistics and Prevention Institute, Medical Economics, University of Zurich, Zurich, Switzerland
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Abstract
INTRODUCTION About 20-40% of patients with multiple myeloma (MM) will present with some degree of renal impairment (RI) and about 25% of patients will experience RI at later disease stages. Patients with MM and RI have poorer overall survival and are at higher risk of early death. AREAS COVERED The mechanisms of acute renal damage in MM are covered and the issues around diagnosis and renal evaluation response are discussed. The importance of optimal supportive care is stressed and the role and effectiveness of different anti-myeloma agents covered including the role of high cut-off hemodialysis, autologous stem cell transplantation and kidney transplant. Expert commentary: Outcomes of patients with RI and rates of renal recovery have improved with the use of novel anti-myeloma agents. Bortezomib-dexamethasone backbone regimes (±third agent) are the current first choice in newly diagnosed patients. In relapsed/refractory disease additional treatment options include newer novel agents.
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Affiliation(s)
- Despoina Fotiou
- a Department of Clinical Therapeutics , National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Meletios A Dimopoulos
- a Department of Clinical Therapeutics , National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Efstathios Kastritis
- a Department of Clinical Therapeutics , National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
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Yadav P, Cook M, Cockwell P. Current Trends of Renal Impairment in Multiple Myeloma. KIDNEY DISEASES 2016; 1:241-57. [PMID: 27536684 DOI: 10.1159/000442511] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/18/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Renal impairment (RI) is a common complication of multiple myeloma (MM). Around 50% of patients with MM have RI at presentation, and up to 5% require dialysis treatment. Severe acute kidney injury (AKI) as a cause of RI is a particular challenge as historically the survival of patients who sustain this complication and require dialysis is very poor. However, in this current period, survival is improving and the focus is on optimum use of novel chemotherapies and the evaluation of extra-corporeal therapies for removal of serum immunoglobulin light chains. SUMMARY RI in patients with MM is commonly associated with excess monoclonal free light chain (FLC) production; myeloma cast nephropathy is the predominant renal pathology in patients presenting with severe RI secondary to AKI. The majority of patients have mild to moderate RI and recover renal function. However, patients with more severe RI, in particular those with a requirement for dialysis, are less likely to recover renal function. Rapid diagnosis and prompt institution of anti-myeloma therapy is an important determinant of renal function recovery, through targeting early and sustained reduction of involved monoclonal FLC. Novel agents are associated with excellent disease response, and bortezomib is now widely used as a first-line agent in the management of MM in patients with severe RI. Extended haemodialysis using high cut-off dialysers is more effective for extracorporeal removal of FLC than plasma exchange, and clinical trials are in process. High-dose chemotherapy with autologous stem cell transplantation does have a role in patients with severe RI but requires careful patient selection. KEY MESSAGES RI is very common in patients with MM, and renal function recovery is associated with improved clinical outcomes. We summarise the epidemiology of MM in the UK, present the impact of RI and renal function recovery on patient outcome, and describe the current management of MM in western countries. FACTS FROM EAST AND WEST (1) A serum creatinine level >2 mg/dl has been reported in 16, 21, 24, and 33% of patients with MM in cohort studies from Japan, Europe, China, and Korea, respectively. A creatinine clearance rate <30 ml/min was observed in 30 and 15% of patients in Chinese and Western MM cohorts, respectively. The commonest cause of severe RI in patients with MM is myeloma cast nephropathy. (2) The efficacy of novel treatments (bortezomib, carfilzomib, thalidomide, and lenalidomide) has predominantly been assessed in Western patients. Bortezomib and dexamethasone are the current standard of care for MM and severe RI in the West. Severe RI is not a contraindication to autologous stem cell transplantation (ASCT). Most of the data are from the West; there are case reports from China describing good outcomes with ASCT. The removal of FLC by high-cut-off hemodialysis is under evaluation in randomized controlled trials (RCTs) in the West. Studies in this area are not yet conducted in China. In China, new treatments, such as bortezomib, are more widely used than before, and favorable results are being reported; however, RCT studies are still needed in this area to confirm the efficacy and safety of this and other novel treatments.
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Affiliation(s)
- Punit Yadav
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK; School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Birmingham Institute of Translational Medicine, Birmingham, UK
| | - Mark Cook
- Birmingham Institute of Translational Medicine, Birmingham, UK; Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK; School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Birmingham Institute of Translational Medicine, Birmingham, UK
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Ueno T, Kikuchi K, Hazue R, Mise K, Sumida K, Hayami N, Suwabe T, Hoshino J, Sawa N, Arizono K, Hara S, Takaichi K, Fujii T, Ohashi K, Ubara Y. Five Sequential Evaluations of Renal Histology in a Patient with Light Chain Deposition Disease. Intern Med 2016; 55:2993-2999. [PMID: 27746438 PMCID: PMC5109568 DOI: 10.2169/internalmedicine.55.6213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 58-year-old man was referred to our institution for an evaluation of nephrotic range proteinuria. Renal biopsy showed a marked expansion of the mesangial matrix and thickening of glomerular basement membrane (GBM) in periodic acid-silver methenamine (PAM). Immunofluorescence (IF) revealed strong staining for the monoclonal kappa light chain. EM demonstrated massive subendothelial and mesangial dense deposits. As a result, light chain deposition disease (LCDD) was diagnosed. Melphalan and prednisolone (MP) therapy was started, which was continued for 10 years with minimal complications. Serial evaluations of renal histology revealed the resolution of nodular lesions and the glomeruli became nearly normal. MP therapy can therefore be an effective therapeutic option for LCDD if it is continued over the long term.
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Glomerular endothelial vesicles in a renal allograft: an unusual pattern of immunoglobulin deposition in a patient with biclonal gammopathy of unknown significance. Am J Surg Pathol 2015; 39:864-9. [PMID: 25723111 DOI: 10.1097/pas.0000000000000406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Paraproteins have varied effects on the kidney on the basis of molecular structure, concentration, and renal function. Prototypical patterns include myeloma cast nephropathy, monoclonal immunoglobulin deposition disease, and amyloid, among others. We report a 69-year-old man with end-stage diabetic nephropathy and biclonal gammopathy of unknown significance. Serum monoclonal immunoglobulin G (IgG)-κ and urine monoclonal free λ light chains were identified during workup for nephrotic syndrome. A native renal biopsy demonstrated diabetic nephropathy, without indication of paraprotein-related pathology. After transplantation, a surveillance biopsy showed endothelialitis (type 2 rejection) and abundant eosinophilic droplets, nearly occluding glomerular capillary loops. Electron microscopy localized tightly packed electron-dense vesicles in glomerular endothelial cells. Immunofluorescence studies revealed IgG-κ-dominant endothelial staining, along with λ monotypic protein resorption droplets in tubules. Two additional biopsies within the following year showed this same paraprotein distribution, with some increase in mesangial sclerosis. Two years after transplant the patient remains asymptomatic with normal creatinine levels. Literature review yields rare cases of immunoglobulin crystalline deposits in multiple glomerular cell types, rarely including endothelial cells; however, this appears to be the first report of monoclonal immunoglobulin vesicles localized solely to endothelial cells. As these vesicles were not seen in the native kidney biopsy, we hypothesize an interaction of alloimmune-mediated endothelial injury and the physiochemical properties of the IgG-κ paraprotein. In addition, this case illustrates simultaneous different patterns of accumulation of monoclonal immunoglobulin and light chain components in this unique patient with biclonal gammopathy of unknown significance.
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Assi LK, McIntyre N, Fraser S, Harris S, Hutchison CA, McIntyre CW, Cockwell P, Taal MW. The Association between Polyclonal Combined Serum Free Light Chain Concentration and Mortality in Individuals with Early Chronic Kidney Disease. PLoS One 2015; 10:e0129980. [PMID: 26132658 PMCID: PMC4489104 DOI: 10.1371/journal.pone.0129980] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 05/14/2015] [Indexed: 01/22/2023] Open
Abstract
A major component of increased mortality risk in people with chronic kidney disease (CKD) is associated with non-traditional cardiovascular risk factors including markers of inflammation. We studied whether a novel marker of systemic inflammation, elevated serum combined polyclonal immunoglobulin free light chains (cFLC), was an independent risk factor for increased all-cause mortality in people with CKD stage 3. In a prospective community based cohort study, 1695 participants with stage 3 CKD and no cases of monoclonal gammopathy had cFLC concentrations measured. cFLC levels were determined using the summation of Freelite kappa and lambda assays. All other bioclinical variables were collected at the time of sample collection. Kaplan-Meier plots and Cox proportional hazards analysis was used to assess the relationship between high cFLC levels (>43.3 mg/L) and mortality. There were 167 deaths (10%) after a median of 1375 days. cFLC levels at recruitment were higher in participants who died compared with those who were alive at the end of the study; median: 46.5 mg/L (IQR: 36.1-65.4 mg/L) and 35.4 mg/L (28.1-46.6 mg/L) respectively, P <0.001. Kaplan-Meier survival analysis demonstrated participants with cFLC >43.3 mg/L levels had an increased risk of mortality compared to people with normal cFLC levels (P <0.001). Elevated cFLC levels were independently associated with worse survival (Hazard ratio: 1.50; 95% confidence interval: 1.04-2.16; P=0.03). Other independent risk factors for worse survival were: older age, male gender, previous cardiovascular event, lower eGFR and higher high sensitivity C-reactive protein (hsCRP). To conclude, high cFLC levels predict increased mortality in people with stage 3 CKD, independent of established risk factors and other markers of inflammation.
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Affiliation(s)
- Lakhvir K. Assi
- The Binding Site Group Ltd, 8 Calthorpe Road, Edgbaston, Birmingham, United Kingdom
| | - Natasha McIntyre
- Division of Medical Sciences and Graduate-Entry Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Simon Fraser
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Scott Harris
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | | | - Chris W. McIntyre
- Division of Medical Sciences and Graduate-Entry Medicine, University of Nottingham, Nottingham, United Kingdom
- Renal Unit, Royal Derby Hospital, Derby, United Kingdom
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Maarten W. Taal
- Division of Medical Sciences and Graduate-Entry Medicine, University of Nottingham, Nottingham, United Kingdom
- Renal Unit, Royal Derby Hospital, Derby, United Kingdom
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Kapoulas S, Raptis V, Papaioannou M. New aspects on the pathogenesis of renal disorders related to monoclonal gammopathies. Nephrol Ther 2015; 11:135-43. [PMID: 25861714 DOI: 10.1016/j.nephro.2014.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple myeloma and other related monoclonal gammopathies are frequently encountered conditions associated with renal damage, especially in elderly population. They are arising from clonal proliferation of plasma cells in bone marrow producing various quantities of abnormal monoclonal immunoglobulins, or their components/fragments. SUMMARY These abnormal proteins differ from normal immunoglobulins in the amino acid sequence and in the three-dimensional structure of the molecule, which may determine their toxicity. Kidney seems to be a target organ as a major catabolic site. The pathology of renal disease is highly heterogeneous involving a variety of different mechanisms, which are divided into immunoglobulin dependent and immunoglobulin independent mechanisms. The Ig-dependent mechanisms may involve the four components of the kidney parenchyma, and the primary structure of these proteins determine the pattern of renal disease. KEY MESSAGE This review summarizes the existing literature in the pathobiology of multiple myeloma, and the pathological properties of the M-proteins, focusing on the mechanisms of the renal manifestations related to these abnormal proteins, especially glomerular injury. Also it supports the opinion that monoclonal gammopathy of undetermined significance (MGUS) should not be used in cases where there is proven renal impairment due to these proteins, even if it is mild and does not meet the current criteria.
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Affiliation(s)
- Stergios Kapoulas
- Section of nephrology and hypertension, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece
| | - Vasileios Raptis
- Section of nephrology and hypertension, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece.
| | - Maria Papaioannou
- Section of hematology, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece
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Ritchie J, Assi LK, Burmeister A, Hoefield R, Cockwell P, Kalra PA. Association of Serum Ig Free Light Chains with Mortality and ESRD among Patients with Nondialysis-Dependent CKD. Clin J Am Soc Nephrol 2015; 10:740-9. [PMID: 25825483 DOI: 10.2215/cjn.09660914] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 09/30/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES High levels of serum polyclonal combined Ig free light chains are associated with inflammation and decreased excretory kidney function, and they are an independent risk factor for mortality. Whether combined Ig free light chain predicted mortality and progression to ESRD in a stages 3-5 CKD cohort was assessed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a prospective cohort study of 872 patients with stages 3-5 CKD (nondialysis) recruited into the Chronic Renal Insufficiency Standards Implementation Study. Patients were recruited to the Chronic Renal Insufficiency Standards Implementation Study in an unselected manner from secondary care nephrology clinics between 2004 and 2010. Combined Ig free light chain was measured at recruitment and analyzed by quartiles. The cohort was followed up for a median of 41.4 months (interquartile range =28.3-68.0 months). Cox regression analysis was undertaken to determine the variables associated with mortality and progression to ESRD. RESULTS Combined Ig free light chain quartiles were <49.4, 49.4-68.8, 68.9-100.7, and >100.7 mg/L. An independent association with death and progression to ESRD was associated with the third and fourth combined Ig free light chain quartiles (quartile 3: death: hazard ratio, 1.49; 95% confidence interval, 1.02 to 2.18; P=0.04; ESRD: hazard ratio, 1.72; 95% confidence interval, 1.0 to 2.97; P=0.05; quartile 4: death: hazard ratio, 1.99; 95% confidence interval, 1.34 to 2.93; P<0.001; ESRD: hazard ratio, 3.73; 95% confidence interval, 2.1 to 6.3; P<0.001). The other independent risk factors were (1) preexisting cardiovascular disease, age >65 years old, and eGFR=15-30 ml/min per 1.73 m(2) for death and (2) age ≤65 years old, eGFR<30 ml/min per 1.73 m(2), urinary protein-to-creatinine ratio >30 mg/mmol, and serum phosphate level >4.65 mg/dl for progression to ESRD. CONCLUSIONS An elevated serum combined Ig free light chain level is an independent risk factor for mortality and progression to ESRD in patients with stages 3-5 CKD managed in secondary care.
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Affiliation(s)
- James Ritchie
- Department of Renal Medicine, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | | | | | - Richard Hoefield
- Department of Renal Medicine, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, Birmingham, United Kingdom; and Division of Immunity and Infection, College of Medical and Dental Science, University of Birmingham, Birmingham, United Kingdom
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal National Health Service Foundation Trust, Salford, United Kingdom;
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Abstract
Monoclonal gammopathy is produced by neoplastic or non-neoplastic expansion of a clone of plasma cells or B lymphocytes. Monoclonal gammopathy of unknown significance is characterized by low levels of the monoclonal protein and a relatively small population of clonal lymphocytes or plasma cells in the bone marrow. In these cases, the patient is asymptomatic with no evidence of overt myeloma or lymphoma. The abnormal serum protein may be present as a complete immunoglobulin molecule or may consist of ≥1 of its components such as light chains or heavy chains. These proteins may cause a variety of diseases in various tissues and organs, of which the kidney appears to be the most vulnerable. Renal involvement in monoclonal gammopathy may occur as part of a generalized disease such as amyloidosis, immunoglobulin deposition disease, and cryoglobulinemia. In addition, there may be evidence of kidney damage by processes which are renal specific. These include light chain proximal tubulopathy, light chain cast nephropathy, and a variety of glomerulopathies encompassing a wide spectrum of disease patterns.
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Kofman T, Zhang SY, Copie-Bergman C, Moktefi A, Raimbourg Q, Francois H, Karras A, Plaisier E, Painchart B, Favre G, Bertrand D, Gyan E, Souid M, Roos-Weil D, Desvaux D, Grimbert P, Haioun C, Lang P, Sahali D, Audard V. Minimal change nephrotic syndrome associated with non-Hodgkin lymphoid disorders: a retrospective study of 18 cases. Medicine (Baltimore) 2014; 93:350-358. [PMID: 25500704 PMCID: PMC4602440 DOI: 10.1097/md.0000000000000206] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Few studies have examined the occurrence of minimal change nephrotic syndrome (MCNS) in patients with non-Hodgkin lymphoma (NHL). We report here a series of 18 patients with MCNS occurring among 13,992 new cases of NHL. We analyzed the clinical and pathologic characteristics of this association, along with the response of patients to treatment, to determine if this association relies on a particular disorder. The most frequent NHLs associated with MCNS were Waldenström macroglobulinemia (33.3%), marginal zone B-cell lymphoma (27.8%), and chronic lymphocytic leukemia (22.2%). Other lymphoproliferative disorders included multiple myeloma, mantle cell lymphoma, and peripheral T-cell lymphoma. In 4 patients MCNS occurred before NHL (mean delay, 15 mo), in 10 patients the disorders occurred simultaneously, and in 4 patients MCNS was diagnosed after NHL (mean delay, 25 mo). Circulating monoclonal immunoglobulins were present in 11 patients. A nontumoral interstitial infiltrate was present in renal biopsy specimens from 3 patients without significant renal impairment. Acute kidney injury resulting from tubular lesions or renal hypoperfusion was present in 6 patients. MCNS relapse occurred more frequently in patients treated exclusively by steroid therapy (77.8%) than in those receiving steroids associated with chemotherapy (25%). In conclusion, MCNS occurs preferentially in NHL originating from B cells and requires an aggressive therapeutic approach to reduce the risk of MCNS relapse.
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Affiliation(s)
- Tomek Kofman
- Service de Néphrologie et Transplantation, Groupe hospitalier Henri-Mondor/Albert-Chenevier, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), AP-HP (Assistance Publique-Hôpitaux de Paris, Créteil), Université Paris Est Créteil, Créteil (TK, DD, PG, PL, DS, VA); Equipe 21, INSERM Unité 955, Université Paris Est Créteil, Créteil (TK, SYZ, AM, DD, PG, PL, DS, VA); Département de Pathologie, Groupe hospitalier Henri-Mondor/Albert-Chenevier, AP-HP, Université Paris Est Créteil, Créteil (CCB, AM); Equipe 9, INSERM Unité 955, Université Paris Est Créteil, Créteil (CCB, CH); Service de Néphrologie, Hôpital Bichat, AP-HP, Université Paris Diderot, Paris (QR); Service de Néphrologie, Hôpital Kremlin Bicêtre, IFRNT, AP-HP, INSERM Unité 1014, Université Paris Sud, Kremlin Bicêtre (HF); Service de Néphrologie, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Paris (AK); Service de Néphrologie et Dialyse, Hôpital Tenon, AP-HP, INSERM Unité 702, Université Pierre et Marie Curie-Paris 6, Paris (EP); Service de Néphrologie et Hémodialyse, Centre Hospitalier de Cambrai (BP); Service de Néphrologie, Hopital Pasteur, Université Nice Sophia Antipolis, Nice (GF); Service de Néphrologie et Transplantation, Hôpital Charles Nicolle, Université de Rouen, Rouen (DB); Service d'Hématologie et Thérapie cellulaire, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours, Université de Tours François Rabelais, Tours (EG); Service de Néphrologie, Centre Hospitalier intercommunal de Poissy Saint Germain en Laye (MS); Service d'Hématologie clinique, Hôpital La Pitié Salpêtrière, AP-HP, Université Pierre et Marie Curie Paris 06, GRC 11 (GRECHY), Paris (DRW); and Unité d'Hémopathies Lymphoïdes, AP-HP, Groupe hospitalier Henri-Mondor/Albert-Chenevier, Université Paris Est Créteil, Créteil (CH), France
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Talbot B, Wright D, Basnayake K. The importance of screening for serum free light chains in suspected cases of multiple myeloma and their impact on the kidney. BMJ Case Rep 2014; 2014:bcr-2014-206688. [PMID: 25326567 DOI: 10.1136/bcr-2014-206688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Multiple myeloma (MM) is the second most common haematological malignancy in the UK. We present a case series of three patients with light chain only myeloma who had normal serum protein electrophoretic studies at screening and were diagnosed using serum and urine free light chain assessment. This series reiterates the importance of thorough and robust screening for MM in patients presenting with renal disease. We review the up to date literature and we highlight the need to screen patients for MM with a combination of serum electrophoresis/immunofixation and either urinary or serum free light chain measurement and to maintain a high index of suspicion regardless of the presence or absence of proteinuria. We also discuss the emerging role of the serum free light chain assay.
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Affiliation(s)
- B Talbot
- Department of Renal Medicine, Brighton and Sussex University Hospitals Trust, Brighton, East Sussex, UK
| | - D Wright
- Department of Histopathology, Brighton and Sussex University Hospitals, Brighton, East Sussex, UK
| | - K Basnayake
- Department of Renal Medicine, Brighton and Sussex University Hospitals Trust, Brighton, East Sussex, UK
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63
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Owen-Casey MP, Sim R, Cook HT, Roufosse CA, Gillmore JD, Gilbertson JA, Hutchison CA, Howie AJ. Value of antibodies to free light chains in immunoperoxidase studies of renal biopsies. J Clin Pathol 2014; 67:661-6. [PMID: 24817705 PMCID: PMC4112424 DOI: 10.1136/jclinpath-2014-202231] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Because immunoglobulin abnormalities may affect the kidney, investigation of renal biopsies requires immunohistological study of light chains. A problem is that most antibodies to light chains react with whole immunoglobulins as well as free light chains, and there are generally many more whole immunoglobulins than free light chains. The usefulness of antibodies that only detected free light chains was investigated. METHODS Antibodies to free light chains were used in an immunoperoxidase method on paraffin sections of 198 renal biopsies, and compared with conventional antibodies against light chains examined by immunofluorescence on 13 frozen sections and by immunoperoxidase on 46 paraffin sections. RESULTS Immunofluorescence and immunoperoxidase were concordant on 10 of 13 biopsies. Immunofluorescence detected slight deposition of light chains in three biopsies not shown by immunoperoxidase, of undetermined clinical significance. Using immunoperoxidase, the free light chain antibodies were more sensitive than conventional antibodies, giving much cleaner staining and better detection of deposits in AL amyloid, light chain deposition disease and cryoglobulinaemic glomerulonephritis. The free light chain antibodies showed discordance or ambiguity between immunohistological and clinical findings in seven (4%) of 185 patients with known immunoglobulin status. These included two of 28 cases of AL amyloid that showed no light chain deposition. The method was not designed for detection of light chain restriction in neoplastic plasma or lymphoplasmacytic cells. CONCLUSIONS Polyclonal antibodies to free light chains are an improvement on conventional antibodies in immunoperoxidase study of paraffin sections of renal biopsies and are useful in everyday practice.
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Affiliation(s)
| | - Rosalind Sim
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - H Terence Cook
- Department of Histopathology, Imperial College School of Medicine, Hammersmith Hospital, London, UK
| | - Candice A Roufosse
- Department of Histopathology, Imperial College School of Medicine, Hammersmith Hospital, London, UK
| | - Julian D Gillmore
- UCL Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, London, UK
| | - Janet A Gilbertson
- UCL Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, London, UK
| | - Colin A Hutchison
- Department of Nephrology, Hawke's Bay District Health Board, Hastings, New Zealand
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64
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Parasuraman R, Wolforth SC, Wiesend WN, Dumler F, Rooney MT, Li W, Zhang PL. Contribution of polyclonal free light chain deposition to tubular injury. Am J Nephrol 2013; 38:465-74. [PMID: 24296691 DOI: 10.1159/000356557] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/22/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Excretion of monoclonal free light chains (MFLC) beyond the renal threshold can cause kidney injury, but evidence for polyclonal free light chains (PFLC)-mediated injury is limited. We aimed to study the degree of PFLC deposition in the proximal tubules of chronic kidney disease (CKD) and hypothesized that excess deposition may contribute to tubular injury. METHODS In this retrospective study, immunohistochemical staining to assess the degree of FLC deposition, periodic acid-Schiff staining for the degree of tubular brush border injury and trichrome staining for interstitial fibrosis were evaluated. Normal renal parenchyma from tumor nephrectomy specimens (control group I, n = 39), minimal change disease controls (group II, n = 13), renal biopsies from CKD and proteinuria (polyclonal study group III, n = 33) and monoclonal light chain nephropathy (group IV, n = 37) were studied. The results of the study including serum creatinine were compared between groups. RESULTS Both polyclonal and monoclonal groups (groups III and IV) had significantly higher light chain deposition and brush border injury by periodic acid-Schiff scores compared to control groups (groups I and II). When the first three polyclonal groups (groups I-III) were analyzed together, polyclonal light chain deposition was significantly correlated with serum creatinine levels, brush border injury and interstitial fibrosis. CONCLUSION The results of our study suggest that in CKD patients with proteinuria, excess PFLC deposition in the proximal tubules may cause acute tubular injury akin to monoclonal gammopathy and lead to renal chronicity.
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Affiliation(s)
- Ravi Parasuraman
- Department of Transplant Surgery, William Beaumont Hospital, Royal Oak, Mich., USA
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65
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Katagiri D, Noiri E, Hinoshita F. Multiple myeloma and kidney disease. ScientificWorldJournal 2013; 2013:487285. [PMID: 24288486 PMCID: PMC3826468 DOI: 10.1155/2013/487285] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/11/2013] [Indexed: 12/22/2022] Open
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.
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Affiliation(s)
- Daisuke Katagiri
- Department of Nephrology and Endocrinology, University Hospital, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
| | - Eisei Noiri
- Department of Nephrology and Endocrinology, University Hospital, University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo 113-8655, Japan
| | - Fumihiko Hinoshita
- Department of Nephrology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjyuku, Tokyo 162-8655, Japan
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66
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Heher EC, Rennke HG, Laubach JP, Richardson PG. Kidney disease and multiple myeloma. Clin J Am Soc Nephrol 2013; 8:2007-17. [PMID: 23868898 DOI: 10.2215/cjn.12231212] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Kidney injury is a common complication of multiple myeloma and other plasma cell dyscrasias, and it is associated with increased mortality. Multiple pathogenic mechanisms can contribute to kidney injury in the patient with myeloma, some of which are the result of nephrotoxic monoclonal Ig and some of which are independent of paraprotein deposition. The pathogenic mechanisms that underlie paraprotein-related kidney disease are increasingly well understood. A novel assay allowing the quantification of free light chains in the serum has aided the diagnosis of new onset disease and allowed for the earlier detection of relapse. Novel myeloma agents have shown considerable promise in reversing renal failure in some patients and improving outcomes. Stem cell transplantation remains a mainstay of management for younger patients with myeloma who are suitable candidates for intensive therapy, whereas the role of new drugs, plasma exchange, and kidney transplantation continues to evolve.
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Affiliation(s)
- Eliot C Heher
- Nephrology Division and Transplantation Center, Massachusetts General Hospital, Boston, Massachusetts;, †Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, ‡Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
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67
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Fabbrini P, Sirtori S, Casiraghi E, Pieruzzi F, Genovesi S, Corti D, Brivio R, Gregorini G, Como G, Carati ML, Viganò MR, Stella A. Polymethylmethacrylate membrane and serum free light chain removal: enhancing adsorption properties. Blood Purif 2013; 35 Suppl 2:52-8. [PMID: 23676837 DOI: 10.1159/000350849] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Polymethylmethacrylate (PMMA) membranes can adsorb a wide variety of uremic toxins including serum free light chains (sFLC). However, limited data are available regarding the clinical use of PMMA in multiple myeloma patients and its maximum adsorption capacity in this setting. AIM This study aimed to measure the capacity of PMMA to adsorb sFLC and identify strategies to improve its efficiency in clinical practice. METHODS Ten patients with dialysis-dependent renal failure and high levels of sFLC were included in the study. Five patients received standard PMMA hemodialysis (HD; n = 18), while in the other 5 patients a new technique called enhanced adsorption dialysis (EAD) was used, which involves PMMA dialyzer replacement after 2 h (n = 19). In all patients, sFLC were measured at the beginning and at the end of each dialysis session to calculate the difference between start and end of treatment and the percentage removal. RESULTS PMMA membranes reduced sFLC in both the PMMA HD and EAD groups. PMMA HD showed similar efficiency on κ and λ percentage removal (22.3 and 21.0%, respectively, n.s.) but, in contrast, had a significantly greater effect on the delta of sFLC in κ [1,555 mg/l (-511 to +6,027)] versus λ [390 mg/l (120-650)] treatments (p = 0.007). EAD treatments only partially increased percentage removal of κ sFLC (22.3-31.0%, p = 0.38), while they had a significantly great effect on λ (21.0-53.1%, p = 0.003). A positive linear correlation was found between delta sFLC and pre-HD sFLC concentrations in PMMA HD κ treatments (r = 0.68, p < 0.02) but not for λ treatments (r = 0.54, p = 0.21), while the analysis of patients receiving EAD demonstrated a strong positive correlation for both κ and λ subtypes (r = 0.81 and r = 0.85, respectively, p < 0.008). In EAD sessions, a positive linear correlation was shown between blood flow during treatment and percentage removal of sFLC (r = 0.58, p = 0.02); however, with PMMA HD such a correlation was not observed (r = 0.28, p = 0.25). CONCLUSIONS PMMA membranes can efficiently adsorb sFLC, but the process is limited by membrane saturation and is different between κ and λ sFLC. The new EAD technique can greatly improve λ removal but only partially act on κ sFLC. Therefore, EAD should be considered a valid economic treatment option without side effects in particular subsets of patients for the removal of sFLC.
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Affiliation(s)
- P Fabbrini
- Clinica Nefrologica, AO San Gerardo Monza, Monza, Italy
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68
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Ardalan MR. Light chain deposition disease; there are reasons for confusion. J Renal Inj Prev 2013; 2:127-8. [PMID: 25340150 PMCID: PMC4206026 DOI: 10.12861/jrip.2013.41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 05/29/2013] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mohammad-Reza Ardalan
- Chronic Kidney Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Bansal T, Garg A, Snowden JA, McKane W. Defining the Role of Renal Transplantation in the Modern Management of Multiple Myeloma and Other Plasma Cell Dyscrasias. Nephron Clin Pract 2012; 120:c228-35. [DOI: 10.1159/000341760] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Cockwell P, Cook M. The rationale and evidence base for the direct removal of serum-free light chains in the management of myeloma kidney. Adv Chronic Kidney Dis 2012; 19:324-32. [PMID: 22920643 DOI: 10.1053/j.ackd.2012.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 06/16/2012] [Accepted: 06/27/2012] [Indexed: 11/11/2022]
Abstract
Myeloma kidney (cast nephropathy) causing severe acute kidney injury occurs in up to 10% of patients with multiple myeloma. The lesion is caused by exposure of the kidneys to high serum levels of free clonal immunoglobulin light chains (LCs) and is associated with very high morbidity and mortality. The current focus on the management of this complication is on early and aggressive treatment to rapidly reduce the serum levels of the immunoglobulin LC clone and protect the kidneys from continuing injury. This has promoted intense interest in the role of direct (extracorporeal) removal of free LCs from serum by plasma exchange or high cut-off (protein permeable) hemodialysis. However, it remains uncertain whether direct removal provides an additional measurable clinical benefit over the current standard of care; rapid institution of treatment with a dexamethasone- and bortezomib-based chemotherapy regime. In this article, we review the rationale for direct removal of free LCs and the current clinical evidence base for plasma exchange and high cut-off hemodialysis.
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Stringer S, Cook M, Cockwell P. Achieving an early myeloma response in patients with kidney impairment. Adv Chronic Kidney Dis 2012; 19:303-11. [PMID: 22920641 DOI: 10.1053/j.ackd.2012.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is increasing evidence, particularly in severe acute kidney injury, that treatment of multiple myeloma with regimens that include dexamethasone in combination with novel chemotherapy agents are associated with an early disease response in most patients. However, the evidence to guide the optimal chemotherapy regimen in patients with kidney impairment is limited, and treatment choices are complicated by the effect of kidney function on drug dosing. Here, we summarize the current status of this field, with a particular focus on chemotherapy regimens that are based on dexamethasone and novel agents and an outline of those areas in which further work is needed to improve the evidence base.
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Haynes R, Leung N, Kyle R, Winearls CG. Myeloma kidney: improving clinical outcomes? Adv Chronic Kidney Dis 2012; 19:342-51. [PMID: 22920645 DOI: 10.1053/j.ackd.2012.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 03/16/2012] [Accepted: 03/16/2012] [Indexed: 12/17/2022]
Abstract
Renal impairment is a common complication of multiple myeloma, affecting 20% to 40% of new cases (depending on the definition). Most cases are mild and easily reversible, but it may manifest as severe acute renal injury requiring dialysis. Renal impairment is associated with a large tumor mass and consequently confers a poor prognosis. The prognosis of myeloma has improved with the introduction of novel agents and autologous stem cell transplantation. These improvements appear to apply equally to patients with renal impairment, although the risk of complication is usually higher in this group of patients. In addition to improved overall survival, there is some evidence that novel therapies have improved the renal prognosis. Treatment with high-dose dexamethasone and bortezomib can rapidly reduce light chain production and provide an opportunity for renal recovery. Although trials of plasma exchange (to remove the nephrotoxic light chain) have shown a disappointing lack of benefit, high cutoff dialysis removes larger quantities of light chain; therefore, trials are underway to investigate whether this can improve the renal prognosis independently of chemotherapy. Outcomes in patients with myeloma kidney do appear to be improving, but more trials are needed (some of which are in progress). There is cause for optimism for physicians and for patients suffering from this condition.
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Haynes R, Hutchison CA, Emberson J, Dasgupta T, Wheeler DC, Townend JN, Landray MJ, Cockwell P. Serum free light chains and the risk of ESRD and death in CKD. Clin J Am Soc Nephrol 2011; 6:2829-37. [PMID: 22034503 DOI: 10.2215/cjn.03350411] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Associations between inflammation and ESRD and death in chronic kidney disease are well established. However, the potential role of the adaptive immune system is uncertain. We aimed to prospectively study the relevance of the adaptive immune system to ESRD and mortality by measuring monoclonal and polyclonal excesses of highly sensitive serum free light chains (sFLCs). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Three hundred sixty-four patients selected from a nephrology outpatient clinic had kappa and lambda sFLCs concentrations and serum immunofixation electrophoresis measured. Cox regression was used to assess the relevance of monoclonal and polyclonal excess of sFLCs to the incidence of ESRD and death (mean follow-up for death 6.0 years). RESULTS After adjustment for baseline eGFR, there was no significant association between monoclonal excess of sFLCs and risk of ESRD or mortality. Baseline log κ and log λ concentrations were positively associated with ESRD risk, but these associations seemed to be due to correlations with eGFR (per 1 SD higher concentration: adjusted hazard ratio 1.05 [95% confidence interval 0.88 to 1.26] and 0.99 [0.83 to 1.19], respectively). For mortality, after adjustment for eGFR plus markers of cardiac damage, there was weak evidence of an association with λ, but not κ, sFLC concentration (fully adjusted hazard ratio 1.33 [95% confidence interval 1.05 to 1.67] per 1 SD higher concentration). CONCLUSIONS Associations between monoclonal and polyclonal excess of sFLCs and risk of ESRD are explained by the correlation between these measures and renal function. We found only weak evidence of an association between polyclonal excess of λ sFLC concentration and mortality.
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Affiliation(s)
- Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom.
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Bellei E, Cuoghi A, Monari E, Bergamini S, Fantoni LI, Zappaterra M, Guerzoni S, Bazzocchi A, Tomasi A, Pini LA. Proteomic analysis of urine in medication-overuse headache patients: possible relation with renal damages. J Headache Pain 2011; 13:45-52. [PMID: 21997203 PMCID: PMC3253154 DOI: 10.1007/s10194-011-0390-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 09/27/2011] [Indexed: 11/26/2022] Open
Abstract
Medication-overuse headache (MOH) is a chronic disorder associated with overuse of analgesic drugs, triptans, non-steroidal anti-inflammatory drugs (NSAIDs) or other acute headache compounds. Various epidemiologic investigations proved that different drug types could cause nephrotoxicity, particularly in chronic patients. The aim of the present work was to analyze, by a proteomic approach, the urinary protein profiles of MOH patients focusing on daily use of NSAIDs, mixtures and triptans that could reasonably be related to potential renal damage. We selected 43 MOH patients overusing triptans (n = 18), NSAIDs (n = 11), and mixtures (n = 14), for 2–30 years with a mean daily analgesic intake of 1.5 ± 0.9 doses, and a control group composed of 16 healthy volunteers. Urine proteins were analyzed by mono-dimensional gel electrophoresis and identified by mass spectrometry analysis. Comparing the proteomic profiles of patients and controls, we found a significantly different protein expression, especially in the NSAIDs group, in which seven proteins resulted over-secreted from kidney (OR = 49, 95% CI 2.53–948.67 vs. controls; OR = 11.6, 95% CI 0.92–147.57 vs. triptans and mixtures groups). Six of these proteins (uromodulin, α-1-microglobulin, zinc-α-2-glycoprotein, cystatin C, Ig-kappa-chain, and inter-α-trypsin heavy chain H4) were strongly correlated with various forms of kidney disorders. Otherwise, in mixtures and in triptans abusers, only three proteins were potentially associated to pathological conditions (OR = 4.2, 95% CI 0.33–53.12, vs. controls). In conclusion, this preliminary proteomic study allowed us to define the urinary protein pattern of MOH patients that is related to the abused drug. According with the obtained results, we believe that the risk of nephrotoxicity should be considered particularly in MOH patients who abuse of NSAIDs.
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Affiliation(s)
- Elisa Bellei
- Medical Faculty, Department of Laboratory, Pathological Anatomy and Forensic Medicine, University Hospital of Modena and Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy.
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