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Dimopoulos MA, Merlini G, Bridoux F, Leung N, Mikhael J, Harrison SJ, Kastritis E, Garderet L, Gozzetti A, van de Donk NWCJ, Weisel KC, Badros AZ, Beksac M, Hillengass J, Mohty M, Ho PJ, Ntanasis-Stathopoulos I, Mateos MV, Richardson P, Blade J, Moreau P, San-Miguel J, Munshi N, Rajkumar SV, Durie BGM, Ludwig H, Terpos E. Management of multiple myeloma-related renal impairment: recommendations from the International Myeloma Working Group. Lancet Oncol 2023; 24:e293-e311. [PMID: 37414019 DOI: 10.1016/s1470-2045(23)00223-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 07/08/2023]
Abstract
Here, the International Myeloma Working Group (IMWG) updates its clinical practice recommendations for the management of multiple myeloma-related renal impairment on the basis of data published until Dec 31, 2022. All patients with multiple myeloma and renal impairment should have serum creatinine, estimated glomerular filtration rate, and free light chains (FLCs) measurements together with 24-h urine total protein, electrophoresis, and immunofixation. If non-selective proteinuria (mainly albuminuria) or involved serum FLCs value less than 500 mg/L is detected, then a renal biopsy is needed. The IMWG criteria for the definition of renal response should be used. Supportive care and high-dose dexamethasone are required for all patients with myeloma-induced renal impairment. Mechanical approaches do not increase overall survival. Bortezomib-based regimens are the cornerstone of the management of patients with multiple myeloma and renal impairment at diagnosis. New quadruplet and triplet combinations, including proteasome inhibitors, immunomodulatory drugs, and anti-CD38 monoclonal antibodies, improve renal and survival outcomes in both newly diagnosed patients and those with relapsed or refractory disease. Conjugated antibodies, chimeric antigen receptor T-cells, and T-cell engagers are well tolerated and effective in patients with moderate renal impairment.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Nelson Leung
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph Mikhael
- Translational Genomics Research Institute, City of Hope Cancer Center, Phoenix, AZ, USA
| | - Simon J Harrison
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | | | - Alessandro Gozzetti
- Department of Hematology, University of Siena, Policlinico S Maria alle Scotte, Siena, Italy
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Katja C Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ashraf Z Badros
- Department of Medicine, University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | | | - Mohamad Mohty
- Department of Hematology, Hôpital Saint-Antoine, Sorbonne University and INSERM UMRs 938, Paris, France
| | - P Joy Ho
- Institute of Haematology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | | | - Paul Richardson
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Joan Blade
- Department of Hematology, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Jesus San-Miguel
- Cancer Center Clinica Universidad de Navarra, CCUN, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Spain
| | - Nikhil Munshi
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Brian G M Durie
- Department of Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, First Department of Medicine, Clinic Ottakring, Vienna, Austria
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece.
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Abstract
Cancer remains a significant cause of morbidity and mortality in kidney transplant recipients, due to long-term immunosuppression. Salient issues to consider in decreasing the burden of malignancy among kidney transplant recipients include pretransplant recipient evaluation, post-transplant screening and monitoring, and optimal treatment strategies for the kidney transplant recipients with cancer. In this review, we address cancer incidence and outcomes, approaches to cancer screening and monitoring pretransplant and post-transplant, as well as treatment strategies, immunosuppressive management, and multidisciplinary approaches in the kidney transplant recipients with cancer.
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Heybeli C, Bentall AJ, Alexander MP, Amer H, Buadi FK, Dispenzieri A, Dingli D, Gertz MA, Issa N, Kapoor P, Kukla A, Kumar S, Lorenz EC, Rajkumar SV, Schinstock CA, Leung N. Kidney Transplant Outcomes of Patients With Multiple Myeloma. Kidney Int Rep 2022; 7:752-762. [PMID: 35497786 PMCID: PMC9039485 DOI: 10.1016/j.ekir.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/04/2021] [Accepted: 01/03/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Data on kidney transplantation (KTx) outcomes of patients with multiple myeloma (MM) are very limited. Methods We investigated the outcomes of patients with MM who underwent KTx between 1994 and 2019. Results A total of 12 transplants from 11 patients were included. At the time of KTx, 6 were classified as having stringent complete response (CR), 2 as CR, 2 as very good partial response (VGPR), and 2 as partial response (PR). With a median follow-up of 40 (minimum–maximum, 5–92) months after KTx, hematologic progression occurred in 9 transplants (75%). There were 3 grafts (25%) that failed, and 5 patients (45.5%) experienced death with functioning allografts. Graft survival at 1 and 5 years was 82.5% and 66%, respectively. Progression-free survival (PFS) rates of the cohort at 1, 3, and 5 years were 83.3%, 55.6%, and 44.4%, respectively. The estimated median PFS of patients who received bortezomib at any time (pre-KTx and/or post-KTx) was not reached, whereas it was 24 months for those who never received bortezomib (P = 0.281). Overall survival (OS) rates of the cohort at 1, 3, and 5 years were 81.8%, 61.4%, and 61.4%, respectively. OS of patients who received bortezomib at any time was 87.5%, 72.9%, and 72.9%, and that for those who never received bortezomib was 66.7%, 33.3%, and 33.3% (P = 0.136). All deaths occurred owing to hematologic progression or treatment-related complications. Conclusion Kidney transplant outcomes of patients with myeloma who received bortezomib before or after KTx seem to be more favorable. Nevertheless, relapse after KTx in MM is still common. More studies are needed to better determine who benefits from a KTx.
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Moreira CL, Hasib Sidiqi M, Buadi FK, Litzow MR, Gertz MA, Dispenzieri A, Russell SJ, Ansell SM, Stegall MD, Prieto M, Dean PG, Nyberg SL, El Ters M, Hogan WJ, Amer H, Cosio FG, Leung N. Long-term Outcomes of Sequential Hematopoietic Stem Cell Transplantation and Kidney Transplantation: Single-center Experience. Transplantation 2021; 105:1615-1624. [PMID: 33031227 DOI: 10.1097/tp.0000000000003477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Experience with sequential hematopoietic stem cell transplant (HSCT) and kidney transplant (KT) is limited. METHODS We conducted a retrospective observational study of adult patients who underwent both HSCT and KT at our center, with a median follow-up of 11 y. RESULTS In our 54 patients cohort (94% autologous HSCT), 36 (67%) patients received HSCT first followed by KT, while 18 (33%) received KT before HSCT. In both groups, AL amyloidosis represented 50% of hematologic diagnosis. Only 4 patients expired due to hematologic disease relapse (2 patients in each group) and only 3 allografts were lost due to hematologic disease recurrence (HSCT first n = 1 and KT first n = 2). Overall 1, 5, and 10 y death-censored graft survival rates were 94%, 94%, and 94%, respectively, for the HSCT first group and 89%, 89%, and 75%, respectively, for the KT first group. Overall 1, 5, and 10 y patients survival rates were 100%, 97% and 90%, respectively, for the HSCT first group and 100%, 76%, and 63%, respectively, for the KT first group. CONCLUSIONS Our study supports safety of sequential KT and HSCT, with improved overall patient survival compared to recipients of HSCT remaining on dialysis and good long-term kidney allograft outcome.
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Affiliation(s)
- Carla Leal Moreira
- Nephrology Department, Centro Hospitalar do Porto, Porto, Portugal
- Nephrology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Porto, Portugal
| | | | | | | | | | | | | | | | - Mark D Stegall
- Division of Transplantation Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Mikel Prieto
- Division of Transplantation Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Patrick G Dean
- Division of Transplantation Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Scott L Nyberg
- Division of Transplantation Surgery, Mayo Clinic Rochester, Rochester, MN
| | - Mireille El Ters
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - William J Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Fernando G Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
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Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, Mandelbrot D, Verna E, Locke J, D'Cunha J, Farr M, Sawinski D, Agarwal PK, Plichta J, Pruthi S, Farr D, Carvajal R, Walker J, Zwald F, Habermann T, Gertz M, Bierman P, Dizon DS, Langstraat C, Al-Qaoud T, Eggener S, Richgels JP, Chang GJ, Geltzeiler C, Sapisochin G, Ricciardi R, Krupnick AS, Kennedy C, Mohindra N, Foley DP, Watt KD. Preexisting melanoma and hematological malignancies, prognosis, and timing to solid organ transplantation: A consensus expert opinion statement. Am J Transplant 2021; 21:475-483. [PMID: 32976703 PMCID: PMC8555431 DOI: 10.1111/ajt.16324] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023]
Abstract
Patients undergoing evaluation for solid organ transplantation (SOT) frequently have a history of malignancy. Only patients with treated cancer are considered for SOT but the benefits of transplantation need to be balanced against the risk of tumor recurrence, taking into consideration the potential effects of immunosuppression. Prior guidelines on timing to transplant in patients with a prior treated malignancy do not account for current staging, disease biology, or advances in cancer treatments. To update these recommendations, the American Society of Transplantation (AST) facilitated a consensus workshop to comprehensively review contemporary literature regarding cancer therapies, cancer stage specific prognosis, the kinetics of cancer recurrence, as well as the limited data on the effects of immunosuppression on cancer-specific outcomes. This document contains prognosis, treatment, and transplant recommendations for melanoma and hematological malignancies. Given the limited data regarding the risk of cancer recurrence in transplant recipients, the goal of the AST-sponsored conference and the consensus documents produced are to provide expert opinion recommendations that help in the evaluation of patients with a history of a pretransplant malignancy for transplant candidacy.
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Affiliation(s)
- David P Al-Adra
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Laura Hammel
- Department of Anesthesiology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - John Roberts
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - E Steve Woodle
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Levine
- Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth Verna
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Jayme Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Maryjane Farr
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - Deirdre Sawinski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jennifer Plichta
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Sandhya Pruthi
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deborah Farr
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Richard Carvajal
- Department of Medicine, New York-Presbyterian/Columbia, New York, New York
| | - John Walker
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fiona Zwald
- Piedmont Transplant Institute, Piedmont Atlanta Hospital, Atlanta, Georgia
| | | | - Morie Gertz
- Hematology Division, Mayo Clinic, Rochester, Minnesota, USA
| | - Philip Bierman
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Don S Dizon
- Lifespan Cancer Institute and Brown University, Providence, Rhode Island
| | - Carrie Langstraat
- Departments of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Talal Al-Qaoud
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Scott Eggener
- Department of Urology, University of Chicago, Chicago, Illinois
| | - John P Richgels
- Department of Urology, University of Chicago, Chicago, Illinois
| | - George J Chang
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Cristina Geltzeiler
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | | | - Rocco Ricciardi
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Cassie Kennedy
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nisha Mohindra
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - David P Foley
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
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Chitty DW, Hartley-Brown MA, Abate M, Thakur R, Wanchoo R, Jhaveri KD, Nair V. Kidney transplantation in patients with multiple myeloma: narrative analysis and review of the last 2 decades. Nephrol Dial Transplant 2020; 37:1616-1626. [PMID: 33295615 DOI: 10.1093/ndt/gfaa361] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 12/17/2022] Open
Abstract
There have been significant advances in the treatment of multiple myeloma in the last 2 decades. Approximately 25% of patients with newly diagnosed myeloma have some degree of kidney impairment. During the course of illness, nearly 50% of myeloma patients will develop kidney disease. Moreover, approximately 10% of myeloma patients have advanced kidney disease requiring dialysis at presentation. Hemodialysis is associated with a significantly reduced overall survival. In the setting of prolonged long-term overall survival due to the use of newer immunotherapeutic agents in the treatment of myeloma, patients with myeloma and advanced kidney disease may benefit from more aggressive management with kidney transplantation. Unfortunately, most data regarding outcomes of kidney transplantation in patients with myeloma come from single center case series. With the advent of novel treatment choices, it remains unclear if outcomes of kidney transplant recipients with myeloma have improved in recent years. In this descriptive systematic review, we coalesced published patient data over the last 20 years to help inform clinicians and patients on expected hematologic and kidney transplant outcomes in this complex population. We further discuss the future of kidney transplantation in patients with paraproteinemia.
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Affiliation(s)
- David W Chitty
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Monique A Hartley-Brown
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Mersema Abate
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Richa Thakur
- Divisions of Hematology-Oncology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA.,Northwell Health Cancer Institute, Hematology/Medical Oncology, New Hyde Park, New York, USA
| | - Rimda Wanchoo
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Kenar D Jhaveri
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
| | - Vinay Nair
- Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, New York, USA
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Current opinions in nephrology and hypertension: kidney transplantation in patients with plasma cell dyscrasias. Curr Opin Nephrol Hypertens 2020; 28:573-580. [PMID: 31403474 DOI: 10.1097/mnh.0000000000000544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Plasma cell dyscrasias encompass a group of hematological disorders characterized by increased production of immunoglobulins by clonal B cells. Kidney involvement is common. Significant advances in the treatment of plasma cell dyscrasias have resulted in improved survival and may permit kidney transplantation in candidates previously denied transplantation. Treatments may also have effects on kidney transplant recipients who develop plasma cell dyscrasias post transplantation. RECENT FINDING The available evidence suggests that transplantation of candidates with nonmultiple myeloma plasma cell dyscrasias provides good outcome with low recurrence rates, so long as the disease has been treated with a complete or good partial response prior to transplantation. Candidates with a history untreated MGRS or a history of multiple myeloma have a high rate of recurrence posttransplant. Kidney transplant recipients who develop plasma cell dyscrasias post transplantation have an increased risk of death and thalidomide-based regimens may increase the risk of rejection. SUMMARY Transplant candidates with a history of plasma cell dyscrasia who are in remission should not be excluded from transplantation. Individuals with multiple myeloma have a high rate of recurrence and myeloma post kidney transplant must be managed carefully.
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