Renal replacement therapy in multiple myeloma and systemic amyloidosis

Continuous Ambulatory Peritoneal Dialysis in End-Stage Renal Disease Due to Multiple Myeloma

Objective

To evaluate (1) the disease course, (2) the response to recombinant human erythropoietin (rHuEPO), and (3) the morbidity and mortality of patients with endstage renal disease (ESRO) dueto multiple myeloma (MM) who were treated with continuous ambulatory peritoneal dialysis (CAPO).

Design

Retrospective study.

Setting

Tertiary teaching hospital -The Toronto Hospital, Toronto, Ontario, Canada.

Patients

Seven patients with ESRO due to MM who were treated with CAPO.

Results

Mean age of the patients was 77.2 years (median 80 years, range 65 88 years). Two were in stage IB, 1 was in stage IIB, and the remaining 4 were in stage IIIB, according to Ourie and Salmon's staging. Three patients received rHuEPO; 2 of these also were receiving chemotherapy for myeloma. The mean rHuEPO requirement was 277 U/kglwk, which was more than other ESRO patients’ requirements. Mean duration of CAPO was 20.6 months (6 -58 months). The peritonitis rate was one episode in 14.4 months. The frequency of hospitalization was once in 5.6 months, and the mean number of days spent in hospital was 20 days per year. Quality of life did not get worse and, if anything, improved marginally while they were on CAPO. Three patients died after a mean survival of 32.7 months, and the remaining 4 patients are still alive.

Conclusions

Myeloma patients with ESRO do fairly well on CAPO without deterioration in their quality of life and with an acceptable peritonitis rate.

Continuous ambulatory peritoneal dialysis in patients with renal failure due to multiple myeloma

Continuous ambulatory peritoneal dialysis (CAPD) is being used only in limited number of patients with renal failure due to multiple myeloma, despite having better preservation of hemoglobin, higher clearance of paraproteins, and higher chances of recovery of renal function than maintenance hemodialysis. We are reporting our short-term experience of five patients with multiple myeloma who presented with renal failure and required long term continuous ambulatory peritoneal dialysis for the treatment of uremia.

Is there a rationale for rationing chronic dialysis? A hospital based cohort study of factors affecting survival and morbidity

OBJECTIVES

To determine factors influencing survival and need for hospitalisation in patients needing dialysis, and to define the potential basis for rationing access to renal replacement therapy.

DESIGN

Hospital based cohort study of all patients starting dialysis over a 4 year recruitment period (follow up 15-63 months). Groups were defined on the basis of age, comorbidity, functional status, and whether dialysis initiation was planned or unplanned.

SETTING

Renal unit in a district general hospital, which acts as the main renal referral centre for four other such hospitals and serves a population of about 1.15 million people.

SUBJECTS

292 patients, mean age 61.3 years (18-92 years, SD 15.8), of whom 193 (66%) were male, and 59 (20%) were patients with diabetes. Dialysis initiation was planned in 163 (56%) patients and unplanned in 129 (44%).

MAIN OUTCOME MEASURES

Overall survival, 1 year survival, and hospitalisation rate.

RESULTS

Factors affecting survival in the Cox's proportional hazard model were Karnofsky performance score at presentation (hazard ratio 0.979, 95% confidence interval 0.972 to 0. 986), comorbidity severity score (1.240, 1.131 to 1.340), age (1.036, 1.018 to 1.054), and myeloma (2.15, 1.140 to 4.042). The Karnofsky performance score used 3 months before presentation was significant (0.970, 0.956 to 0.981), as was unplanned presentation in this model (1.796, 1.233 to 2.617). Using these factors, a high risk group of 26 patients was defined, with 19.2% 1 year survival. Denying dialysis to this group would save 3.2% of the total cost of the chronic programme but would sacrifice five long term survivors. Less rigorous definition of the high risk group would save more money but lose more long term survivors.

CONCLUSIONS

Severity of comorbid conditions and functional capacity are more important than age in predicting survival and morbidity of patients on dialysis. Late referral for dialysis affects survival adversely. Denial of dialysis to patients in an extremely high risk group, defined by a new stratification based on logistic regression, would be of debatable benefit.

Continuous Ambulatory Peritoneal Dialysis in End-Stage Renal Disease Due to Multiple Myeloma

Objective

To evaluate (1) the disease course, (2) the response to recombinant human erythropoietin (rHuEPO), and (3) the morbidity and mortality of patients with endstage renal disease (ESRO) due to multiple myeloma (MM) who were treated with continuous ambulatory peritoneal dialysis (CAPO).

Design

Retrospective study.

Setting

Tertiary teaching hospital -The Toronto Hospital, Toronto, Ontario, Canada.

Patients

Seven patients with ESRO due to MM who were treated with CAPO.

Results

Mean age of the patients was 77.2 years (median 80 years, range 65 88 years). Two were in stage IB, 1 was in stage lIB, and the remaining 4 were in stage IIIB, according to Ourie and Salmon's staging. Three patients received rHuEPO; 2 of these also were receiving chemotherapy for myeloma. The mean rHuEPO requirement was 277 U/kglwk, which was more than other ESRO patients’ requirements. Mean duration of CAPO was 20.6 months (6 –58 months). The peritonitis rate was one episode in 14.4 months. The frequency of hospitalization was once in 5.6 months, and the mean number of days spent in hospital was 20 days per year. Quality of life did not get worse and, if anything, improved marginally while they were on CAPO. Three patients died after a mean survival of 32.7 months, and the remaining 4 patients are still alive.

Conclusions

Myeloma patients with ESRO do fairly well on CAPO without deterioration in their quality of life and with an acceptable peritonitis rate.