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Sharma R, Jain A, Jandial A, Lad D, Khadwal A, Prakash G, Nada R, Aggarwal R, Ramachandran R, Varma N, Malhotra P. Lack of Renal Recovery Predicts Poor Survival in Patients of Multiple Myeloma With Renal Impairment. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:626-634. [PMID: 35610119 DOI: 10.1016/j.clml.2022.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Renal impairment (RI) confers a poor prognosis in multiple myeloma. Reversibility of renal function is associated with improved survival in such patients. Patients in developing countries often present at an advanced stage and renal impairment is present in up to 40% of patients at diagnosis. We studied the renal outcome and survival of these patients with bortezomib-based induction therapy. MATERIALS AND METHODS It was a single-center prospective study in a tertiary care multi-specialty institute in patients of newly diagnosed multiple myeloma (NDMM) who presented with RI from July 2018 to December 2019. The diagnosis of multiple myeloma was made based on IMWG14 criteria. All patients received bortezomib and or immunomodulatory drug-based triplet or quadruplet induction therapy. Hematological and renal outcomes were assessed as per IMWG 2016 criteria. RESULTS Among 216 consecutive patients of NDMM, RI was seen in 91 (42.2%) patients. The median age of 91 patients was 60 years. (range- 32-80 years). Light chain myeloma was seen in 26% (n = 24) of patients. The median estimated glomerular filtration rate (eGFR) was 15.36 mL/min (3.1-38 mL/min) and a majority of patients were in the advanced ISS stage. (ISS III = 85.7%). Thirty-six (39.5%) patients received hemodialysis at presentation. Renal response was seen in 67 (73%) patients and 20 (out of 36; 55%) became dialysis independent over a median time of 38 days (Range 15-160 days). At a median follow-up of 14.7 months, 30 (33%) patients had died, of which, 14 (15.4%) patients had early mortality (within 2 months of diagnosis). Presence of light chain myeloma and cast nephropathy (definite or probable) were identified as independent predictors of poor renal recovery on multivariate analysis. (HR = 2.841; 95% CI [1.471-5.486], P = .002 for light chain myeloma; HR = 1.859; 95% CI (1.087-3.180); P = .024 for cast nephropathy) Patients with low eGFR at presentation (<12.5 mL/min) were more likely to have persistent renal insufficiency. (HR-3.521; 95% CI (1.856-6.679), P = .000). Patients who attained sustained renal recovery had improved survival as compared to patients in whom renal function failed to improve. (median OS- not reached vs. 8.3 months, P = .000) Achievement of hematological response and independence from hemodialysis was associated with improved survival on multivariate analysis. CONCLUSION Renal impairment was reversible in almost three-fourths of NDMM patients. achievement of hematological response and hemodialysis independence were independent predictors of improved overall survival in NDMM patients with RI.
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Affiliation(s)
- Rintu Sharma
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ritu Aggarwal
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Neelam Varma
- Departement of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Hu M, Wang Q, Liu B, Ma Q, Zhang T, Huang T, Lv Z, Wang R. Chronic Kidney Disease and Cancer: Inter-Relationships and Mechanisms. Front Cell Dev Biol 2022; 10:868715. [PMID: 35663394 PMCID: PMC9158340 DOI: 10.3389/fcell.2022.868715] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) has been recognized as an increasingly serious public health problem globally over the decades. Accumulating evidence has shown that the incidence rate of cancer was relatively higher in CKD patients than that in general population, which, mechanistically, may be related to chronic inflammation, accumulation of carcinogenic compounds, oxidative stress, impairment of DNA repair, excessive parathyroid hormone and changes in intestinal microbiota, etc. And in patients with cancer, regardless of tumor types or anticancer treatment, it has been indicated that the morbidity and incidence rate of concomitant CKD was also increased, suggesting a complex inter-relationship between CKD and cancer and arousing increasing attention from both nephrologists and oncologists. This narrative review focused on the correlation between CKD and cancer, and underlying molecular mechanisms, which might provide an overview of novel interdisciplinary research interests and the potential challenges related to the screening and treatment of CKD and cancer. A better understanding of this field might be of help for both nephrologists and oncologists in the clinical practice.
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Affiliation(s)
- Mengsi Hu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qianhui Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiqi Ma
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tingwei Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tongtong Huang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhimei Lv
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Acute kidney injury in cancer patients. Clin Exp Nephrol 2021; 26:103-112. [PMID: 34499266 DOI: 10.1007/s10157-021-02131-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We want to know the causes of AKI in oncology patients, including disease-related complications and the nephrotoxicity of chemotherapy drugs, in order to provide more useful clinical information. METHODS In this review, an electronic search of the English language literature was performed in the database PubMed, with the results enriched by manual searches and citation mining, factors investigated in the selected articles included acute kidney injury, oncology, chemotherapy, anticancer drug, antitumor drug. RESULTS According to the searched articles, we summarized the causes (including pre-renal, intrinsic renal, and post-renal lesion) of AKI in cancer patients and the corresponding management measures. Among the pre-renal factors we mainly described hypercalcemia, hematopoietic cell transplantation, post-renal factors we mainly described hemorrhagic cystitis, and intrinsic renal factors we mainly described thrombotic microangiopathy, chemotherapeutics, tumor lysis syndrome, cast nephropathy, in which the emphasis was on chemotherapy drug associated AKI and its treatment. CONCLUSIONS AKI is not uncommon in cancer patients, and has diverse causes and negative outcomes. Both nephrologists and oncologists need to be aware of the unique reasons of AKI in this population and its optimal management.
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Renal response in real-world carfilzomib- vs bortezomib-treated patients with relapsed or refractory multiple myeloma. Blood Adv 2021; 5:367-376. [PMID: 33496733 DOI: 10.1182/bloodadvances.2019001059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 08/02/2020] [Indexed: 12/15/2022] Open
Abstract
In the phase 3 ENDEAVOR study, carfilzomib-dexamethasone (Kd) improved survival over bortezomib-dexamethasone (Vd) in patients with relapsed or refractory multiple myeloma (RRMM), regardless of baseline renal function. This real-world study compared renal response in patients with RRMM (1-3 prior lines) and renal impairment (estimated glomerular filtration rate ≤50 mL/min) treated with Kd vs Vd. Electronic medical records data from the Oncology Services Comprehensive Electronic Records database were assessed (from January 2012 through February 2018). Time to renal response (defined according to International Myeloma Working Group criteria) was evaluated using the Kaplan-Meier method and log-rank test. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated for renal overall response (ROR) and renal complete response (RCR) using Cox proportional hazard models adjusted for baseline covariates. Included were 543 Kd-treated and 1005 Vd-treated patients. In line 2 (2L), compared with Vd, Kd achieved significantly higher ROR (51.4% vs 39.6%; P < .0001) and RCR (26.6% vs 22.2%; P = .0229). After baseline covariate adjustment, 2L patients receiving Kd vs Vd were 45% more likely to achieve ROR (IRR, 1.45; 95% CI, 1.18-1.78), and 68% were more likely to achieve RCR (IRR, 1.68; 95% CI, 1.24-2.28). The renal response benefit with Kd remained consistent in 2L to line 4 (4L). In a combined analysis of patients receiving Kd and Vd (2L and 2L-4L), renal responders had longer overall survival and time to next treatment than renal nonresponders. These results demonstrate improved real-world effectiveness of Kd over Vd in RRMM renal rescue, and the positive association between renal response and improved survival.
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Zmorzynski S, Szudy-Szczyrek A, Popek-Marciniec S, Korszen-Pilecka I, Wojcierowska-Litwin M, Luterek M, Chocholska S, Styk W, Swiderska-Kołacz G, Januszewska J, Mielnik M, Hus M, Filip AA. ACE Insertion/Deletion Polymorphism (rs4646994) Is Associated With the Increased Risk of Multiple Myeloma. Front Oncol 2019; 9:44. [PMID: 30788288 PMCID: PMC6372536 DOI: 10.3389/fonc.2019.00044] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/16/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction: The insertion (I allele) deletion (D allele) polymorphism of ACE gene (rs4646994) may influence the etiopathogenesis of multiple myeloma (MM). ACE gene is expressed in bone marrow cells and encodes angiotensin converting enzyme (ACE). It converts angiotensin I to active peptide angiotensin II, which stimulates proliferation of hematopoietic stem cells. This suggests possible association of ACE I/D gene polymorphism with MM. The aim of our study was to check possible impact of this polymorphism on risk of development and outcome of MM, as well as, sensitivity to bortezomib in cell cultures derived from MM patients. Objects and Methods: Genomic DNA from 98 newly diagnosed MM patients and 100 healthy blood donors were analyzed by PCR method. Chromosomal aberrations were detected by use of cIg-FISH. In a subgroup of 40 MM patients nucleated bone marrow cells were treated with bortezomib in vitro. Results: The Hardy-Weinberg equilibrium test showed that genotypic frequencies diverged significantly from the equilibrium. The differences between I and D allele frequencies in control and study population were significant (p = 0.046). We observed the association between DD genotype and more than 2-fold risk of MM - OR = 2.69; p < 0.0001. We did not detect any significant differences among studied genotypes regarding clinical and laboratory parameters. Moreover, we did not observe the association between survival of MM patients and I/D genotypes. Bortezomib increased number of apoptotic and necrotic cells, but the only statistically significant differences were observed in the number of viable cells at 1 nM between ID and DD genotypes (p = 0.026). Conclusion: Presented results confirmed the significant relationship between ACE (I/D) polymorphism and risk of MM development. We did not observe the association of ACE I/D polymorphism with disease outcome and bortezomib in vitro sensitivity.
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Affiliation(s)
- Szymon Zmorzynski
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
| | - Aneta Szudy-Szczyrek
- Chair and Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Sylwia Popek-Marciniec
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
| | - Iwona Korszen-Pilecka
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
| | | | - Małgorzata Luterek
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
| | - Sylwia Chocholska
- Chair and Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Wojciech Styk
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
| | | | | | - Michal Mielnik
- Chair and Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Marek Hus
- Chair and Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Agata A Filip
- Department of Cancer Genetics with Cytogenetic Laboratory, Medical University of Lublin, Lublin, Poland
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Carfilzomib vs bortezomib in patients with multiple myeloma and renal failure: a subgroup analysis of ENDEAVOR. Blood 2018; 133:147-155. [PMID: 30478094 DOI: 10.1182/blood-2018-06-860015] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/27/2018] [Indexed: 12/20/2022] Open
Abstract
In ENDEAVOR, carfilzomib (56 mg/m2) and dexamethasone (Kd56) demonstrated longer progression-free survival (PFS) over bortezomib and dexamethasone (Vd) in patients with relapsed/refractory multiple myeloma (RRMM). Here we evaluated Kd56 vs Vd by baseline renal function in a post hoc exploratory subgroup analysis. The intent-to-treat population included 929 patients (creatinine clearance [CrCL] ≥15 to <50 mL/min, n = 85 and n = 99; CrCL 50 to <80 mL/min, n = 186 and n = 177; and CrCL ≥80 mL/min, n = 193 and n = 189 for Kd56 and Vd arms, respectively). In these respective subgroups, median PFS was 14.9 vs 6.5 months (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.320-0.757), 18.6 vs 9.4 months (HR, 0.48; 95% CI, 0.351-0.652), and not reached (NR) vs 12.2 months (HR, 0.60; 95% CI, 0.434-0.827) for those receiving Kd56 vs Vd, respectively; median overall survival (OS) was 42.1 vs 23.7 months (HR, 0.66; 95% CI, 0.443-0.989), 42.5 vs 32.8 months (HR, 0.83; 95% CI, 0.626-1.104), and NR vs 42.3 months (HR, 0.75; 95% CI, 0.554-1.009). Complete renal response (ie, CrCL improvement to ≥60 mL/min in any 2 consecutive visits if baseline CrCL <50 mL/min) rates were 15.3% (95% CI, 8.4-24.7) and 14.1% (95% CI, 8.0-22.6) for those receiving Kd56 vs Vd, respectively. In a combined Kd56 and Vd analysis, complete renal responders had longer median PFS (14.1 vs 9.4 months; HR, 0.805; 95% CI, 0.438-1.481) and OS (35.3 vs 29.7 months; HR, 0.91; 95% CI, 0.524-1.577) vs nonresponders. Grade ≥3 adverse event rates in the respective subgroups were 87.1% vs 79.4%, 84.4% vs 71.8%, and 77.1% vs 65.9% for those receiving Kd56 vs Vd, respectively. Thus, Kd56 demonstrated PFS and OS improvements over Vd in RRMM patients regardless of their baseline renal function. The ENDEAVOR trial was registered at www.clinicaltrials.gov as #NCT01568866.
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Rafae A, Malik MN, Abu Zar M, Durer S, Durer C. An Overview of Light Chain Multiple Myeloma: Clinical Characteristics and Rarities, Management Strategies, and Disease Monitoring. Cureus 2018; 10:e3148. [PMID: 30345204 PMCID: PMC6191009 DOI: 10.7759/cureus.3148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Light chain multiple myeloma (LCMM) constitutes approximately 15% of patients with multiple myeloma (MM). It has a poorer prognosis when compared to immunoglobulin (Ig) G or IgA variant. We performed a comprehensive literature search on LCMM and identified a total of 390 articles. After a detailed screening, six studies involving a total of 1054 LCMM patients were included. A literature review revealed bone pain and renal failure as the most common initial sign and symptoms while extramedullary disease (EMD) was acquired later during the progression of the disease. Bortezomib has shown superior efficacy in LCMM patients over nonbortezomib regimens as demonstrated by better overall response rate (95.5% vs. 60%), progression-free survival (PFS) (25% vs. 9% at two years), and overall survival (OS) (24% vs. 9% at five years). Moreover, better PFS was seen, when bortezomib was used in combination with bendamustine compared to dexamethasone (95% vs. 25% at two years). Similarly, better OS (90% at two years) was observed with bortezomib in combination with bendamustine. Monitoring of disease should include serum free light chain levels, as literature review revealed that serum assays were more sensitive in indicating the disease and predicting PFS and OS as compared to urine assays. We provide presentation patterns, clinical rarities, management strategies including their efficacy, and disease monitoring in patients with LCMM in our review paper.
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Affiliation(s)
- Abdul Rafae
- Hematology and Oncology, The University of Arizona, Tucson, USA
| | - Mustafa N Malik
- Hematology and Oncology, The University of Arizona, Tucson, USA
| | | | - Seren Durer
- Hematology and Oncology, University of Arizona, Tucson, USA
| | - Ceren Durer
- Hemtology and Oncology, The University of Arizona, Tucson, USA
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Chang CF, Chien WC, Chung CH, Lee JC, Hsu SN, Chen JH. Impact of hemodialysis on the prognosis of multiple myeloma: A nationwide population-based study and single-institute analysis. Oncol Lett 2018; 16:1991-2002. [PMID: 30008893 DOI: 10.3892/ol.2018.8857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/19/2018] [Indexed: 12/20/2022] Open
Abstract
Myeloma-associated kidney disease (MRKD) occurs in ≤40% patients with multiple myeloma (MM). The impact of hemodialysis (HD) on patients with MM was investigated. Between 2000 and 2010, a total of 1,610 patients in Taiwan were enrolled from the National Health Institute Research Database. MM was an independent risk factor for HD following adjustment via multivariate logistic regression analysis (adjusted hazard ratio, 7.347; 95% confidence interval, 6.156-8.768; log-rank test, P<0.001). In addition, a notable decrease in survival rate was determined in patients with MM who underwent HD in the first year since diagnosis of MM. A total of 198 (61.49%) patients received HD in the first year. Patients with MM with a lower frequency of HD in the first year had a relatively good prognosis. The present study confirmed that MM was a risk factor for HD. Significant early mortality in the first year was determined in patients with MM who underwent HD; however, renal recovery following therapeutic management was a prognostic factor. In addition to anti-myeloma therapy, early initiation of HD was beneficial following risk stratification of MRKD; however, an increased probability of recovery of renal function and discontinuation of dialysis, was demonstrated in patients with MM following HD, compared with patients with MM without HD.
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Affiliation(s)
- Chao-Feng Chang
- Department of Medicine, Division of Gastroenterology, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C
| | - Wu-Chien Chien
- Department of Medical Research, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C.,School of Public Health, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C.,Taiwanese Injury Prevention and Safety Promotion Association, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C
| | - Jih-Chin Lee
- Department of Otolaryngology-Head and Neck Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C
| | - Shun-Neng Hsu
- Department of Medicine, Division of Nephrology, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C
| | - Jia-Hong Chen
- Department of Medicine, Division of Hematology/Oncology, National Defense Medical Center, Tri-Service General Hospital, Taipei 11490, Taiwan, R.O.C.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan, R.O.C
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Sens F, Chaintreuil D, Jolivot A, Guebre-Egziabher F, Robinson P, Karlin L, Bridoux F, Juillard L. Effectiveness of IHD with Adsorptive PMMA Membrane in Myeloma Cast Nephropathy: A Cohort Study. Am J Nephrol 2017; 46:355-363. [PMID: 29017155 DOI: 10.1159/000481461] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/07/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND In patients with cast nephropathy and acute kidney injury (AKI) requiring dialysis, the reduction of serum free light chains (FLC) using chemotherapy and intensive hemodialysis (IHD) with a high cut-off filter may improve renal and patient outcomes. We evaluated the effectiveness of a combination of chemotherapy and IHD with an adsorbent polymethylmethacrylate membrane (IHD-PMMA) on renal recovery and survival. METHODS A single-center retrospective cohort-study was conducted. Between 2007 and 2014, patients with dialysis-dependent acute cast nephropathy treated with chemotherapy and IHD-PMMA were included. Patients had six 6-h hemodialysis sessions a week, until predialysis serum FLC fell below 200 mg/L, for a maximum of 3 weeks. Primary outcomes were renal recovery, defined as dialysis independence, and survival. RESULTS Seventeen patients were included, all with stage 3 AKI. All received chemotherapy, mostly based on bortezomib and steroids (88%). Twelve patients (71%) achieved renal recovery, usually within 60 days (92%). At 3 months, the overall hematological response rate was 57%; hematological response was maintained for at least 2 years in 86% of responders. At 6, 12, and 24 months, 76, 75, and 62% of patients were alive, respectively. Higher reduction in involved FLC by day 12 (p = 0.022) and day 21 (p = 0.003) was associated with renal recovery. Patients with FLC reduction rate >50% by day 21 experienced a lower mortality (hazard ratio 0.10, 95% CI 0.02-0.63). CONCLUSION In patients with dialysis-dependent myeloma cast nephropathy, early FLC removal by IHD-PMMA combined with chemotherapy was associated with high rates of renal recovery and survival.
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Affiliation(s)
- Florence Sens
- Hospices Civils de Lyon, Department of Nephrology, Edouard Herriot Hospital, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
- Hospices Civils de Lyon, Department of Medical Information Evaluation and Research, Lyon, France
- FCRIN INI-CRCT, Nancy, France
| | - Déborah Chaintreuil
- Hospices Civils de Lyon, Department of Nephrology, Edouard Herriot Hospital, Lyon, France
| | - Anne Jolivot
- Hospices Civils de Lyon, Department of Nephrology, Edouard Herriot Hospital, Lyon, France
| | - Fitsum Guebre-Egziabher
- Grenoble University Hospital, Department of Nephrology, Dialysis and Transplantation, La Tronche, France
| | - Philip Robinson
- Hospices Civils de Lyon, Direction de la Recherche Clinique et de l'Innovation, Lyon, France
| | - Lionel Karlin
- Hospices Civils de Lyon, Department of Medical Information Evaluation and Research, Lyon, France
- Hospices Civils de Lyon, Department of Hematology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Frank Bridoux
- Poitiers University Hospital, Department of Nephrology, Dialysis and Transplantation, Poitiers, France
| | - Laurent Juillard
- Hospices Civils de Lyon, Department of Nephrology, Edouard Herriot Hospital, Lyon, France
- Hospices Civils de Lyon, Department of Medical Information Evaluation and Research, Lyon, France
- Poitiers University Hospital, Department of Nephrology, Dialysis and Transplantation, Poitiers, France
- OPeRa, CARMEN, Lyon 1 Claude Bernard University, Villeurbanne, France
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Hudier L, Decaux O, Haddj-Elmrabet A, Lino M, Mandart L, Siohan P, Renaudineau E, Sawadogo T, Lamy De La Chapelle T, Oger E, Bridoux F, Vigneau C. Intensive haemodialysis using PMMA dialyser does not increase renal response rate in multiple myeloma patients with acute kidney injury. Clin Kidney J 2017; 11:230-235. [PMID: 29644064 PMCID: PMC5887381 DOI: 10.1093/ckj/sfx079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/19/2017] [Indexed: 02/02/2023] Open
Abstract
Background Intensive haemodialysis (IHD) in addition to bortezomib-based chemotherapy might be efficient to rapidly decrease serum immunoglobulin-free light chains removal in patients with multiple myeloma (MM) and to improve renal prognosis and survival. Methods The aim of this retrospective multi-centre study was to compare the efficacy (renal recovery rate) of IHD and of standard haemodialysis (SHD) in patients with MM and dialysis-dependent acute kidney injury (AKI), concomitantly treated with bortezomib-based chemotherapy. Results We selected 41 patients with MM and dialysis-dependent AKI, most likely due to myeloma cast nephropathy (MCN), and who were treated in eight French hospitals between January 2007 and June 2011. Patients were classified in two groups according to dialysis regimen: IHD [n = 21, with a mean of 11.3 dialysis sessions all with poly(methyl methacrylate) (PMMA) membranes for 13.2 days] and SHD (n = 20 patients, mostly three times per week, 31% with PMMA membrane). The main outcome was dialysis-independence at 3 months. At 3 months, 15 patients could stop dialysis: 8 (38.1%) in the IHD and 7 (35%) in the SHD group (P = 1). Moreover, 14 (56%) of the 25 patients who did show haematological response and only one of the 16 patients who did not were dialysis-independent (P = 0.002) at 3 months. Conclusions The results of this retrospective study did not show any clear renal benefit of IHD in patients with MM and MCN compared with SHD. Conversely, they underline the importance of the haematological response to chemotherapy for the renal response and patient prognosis.
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Affiliation(s)
- Laurent Hudier
- Centre hospitalier Broussais, Service de Néphrologie-Hémodialyse, Saint-Malo, France
| | - Olivier Decaux
- CHU Rennes, Service de Médecine Interne, Rennes, France
- CHU Rennes, Service de Néphrologie, Rennes, France
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
| | | | - Marie Lino
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
| | - Lise Mandart
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
| | - Pascale Siohan
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
| | - Eric Renaudineau
- Centre hospitalier Broussais, Service de Néphrologie-Hémodialyse, Saint-Malo, France
| | - Theophile Sawadogo
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
| | - Thierry Lamy De La Chapelle
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
- Université de Rennes 1, Inserm U917, Rennes, France
| | - Emmanuel Oger
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
| | - Frank Bridoux
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
| | - Cécile Vigneau
- CHU Rennes, Service de Néphrologie, Rennes, France
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
- Université de Rennes 1, Inserm U917, Rennes, France
- Université de Rennes 1, IRSET, Rennes, France
- Correspondence and offprint requests to: Cécile Vigneau; E-mail:
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11
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Wu CK, Yang AH, Lai HC, Lin BS. Combined proximal tubulopathy, crystal-storing histiocytosis, and cast nephropathy in a patient with light chain multiple myeloma. BMC Nephrol 2017; 18:170. [PMID: 28545410 PMCID: PMC5445476 DOI: 10.1186/s12882-017-0584-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 05/15/2017] [Indexed: 11/30/2022] Open
Abstract
Background The diagnosis of myeloma, a plasma dyscrasia, often results from the workup of unexplained renal disease. Persistent renal failure in myeloma is commonly caused by tubular nephropathy due to circulating immunoglobulins and free light chains. Myeloma cast nephropathy is characterized by crystalline precipitates of monoclonal light chains within distal tubules. Immunoglobulin crystallization rarely occurs intracellularly, within proximal tubular cells (light chain proximal tubulopathy) and interstitial histiocytes (crystal-storing histiocytosis). We present a case report of a rare simultaneous occurrence of light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy in a patient with κ light chain multiple myeloma. Case presentation A 48-years-old man presented with uremia and anemia. Laboratory examination revealed low levels of serum IgG, IgA, and IgM. Serum and urine immunofixation electrophoresis showed a free κ monoclonal band. Bone marrow aspiration and biopsy revealed hypercellularity with marked plasmacytosis. Light microscopy revealed eosinophilic cuboid- and rhomboid-shaped crystals in the cytoplasm of proximal tubular epithelial cells, diffuse large mononuclear and multinuclear cells in the interstitium, and obstructed distal tubules with cast and giant cell reaction. Immunohistochemical examination indicated intense staining for κ light chains within casts, histiocytes, and tubular epithelial cells. Electron microscopy revealed electro-dense cuboid-, rhomboid-, or needle-shaped crystalline inclusions in proximal tubular epithelial cells and interstitial histiocytes. According to these results, we confirmed that this patient with myeloma exhibited simultaneous light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy, which were attributed to monoclonal κ light chains. In addition to dialysis, the patient received induction chemotherapy with a combination of bortezomib, cyclophosphamide, and dexamethasone, followed by maintenance therapy with thalidomide. However, the patient did not regain renal function even when less than 5% plasma cells were detected in the bone marrow. Conclusion To the best of our knowledge, this is the first report of simultaneous light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy in κ light chain multiple myeloma.
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Affiliation(s)
- Chung-Kuan Wu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - An-Hang Yang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Chih Lai
- Division of Hematology and Oncology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Bing-Shi Lin
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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12
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Affiliation(s)
- Mitchell H Rosner
- From the Division of Nephrology, University of Virginia Health System, Charlottesville (M.H.R.); and the Section of Nephrology, Yale University School of Medicine, New Haven, and the Veterans Affairs Medical Center, West Haven - both in Connecticut (M.A.P.)
| | - Mark A Perazella
- From the Division of Nephrology, University of Virginia Health System, Charlottesville (M.H.R.); and the Section of Nephrology, Yale University School of Medicine, New Haven, and the Veterans Affairs Medical Center, West Haven - both in Connecticut (M.A.P.)
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13
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Quach H, White D, Spencer A, Ho PJ, Bhutani D, White M, Inamdar S, Morris C, Ou Y, Gyger M. Pharmacokinetics and safety of carfilzomib in patients with relapsed multiple myeloma and end-stage renal disease (ESRD): an open-label, single-arm, phase I study. Cancer Chemother Pharmacol 2017; 79:1067-1076. [PMID: 28424963 PMCID: PMC5438822 DOI: 10.1007/s00280-017-3287-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/09/2017] [Indexed: 11/17/2022]
Abstract
Purpose The pharmacokinetics (PK) of carfilzomib have been previously studied in multiple myeloma patients with varying degrees of renal impairment (normal, mild, moderate, severe, and end-stage renal disease [ESRD]) at doses of 15 and 20 mg/m2. This study evaluated carfilzomib PK at higher doses of 27 and 56 mg/m2 in normal renal function and ESRD patients. Methods Patients received carfilzomib on two consecutive days/week for 3 weeks every 28-day cycle: 20 mg/m2 (cycle 1 day 1–2), escalated to 27 mg/m2 on cycle 1 day 8; if tolerated, 56 mg/m2 starting cycle 2 day 1. The primary objective was PK assessment with safety/tolerability and response rate as secondary and exploratory objectives, respectively. Results 26 patients were enrolled (15 normal, 11 ESRD). There was a trend toward higher area under the concentration time curve (AUC) and maximum concentration in ESRD versus normal renal function patients; however, high interpatient PK variability was discerned. Relative to patients with normal renal function, ESRD patients showed 33% higher AUC. Overall response rate was 43% for the normal renal function and 60% for the ESRD groups. Safety findings were generally similar between the two groups and consistent with the known safety profile of carfilzomib in multiple myeloma patients. Conclusion There were no meaningful differences in PK between patients with normal renal function and ESRD in light of carfilzomib exposure–response relationships. These results continue to support dosing recommendation that no starting dose adjustment of carfilzomib appears warranted in patients with baseline renal impairment.
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Affiliation(s)
- Hang Quach
- St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,University of Melbourne, Parkville, VIC, 3010, Australia
| | - Darrell White
- Dalhousie University and Queen Elizabeth II Health Sciences Centre, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, The Alfred Hospital, 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - P Joy Ho
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, 2050, Australia.,Bosch Institute, University of Sydney, Sydney, NSW, 2006, Australia
| | - Divaya Bhutani
- Barbara Ann Karmanos Cancer Institute, 4100 John R St, Detroit, MI, 48201, USA
| | - Mike White
- Amgen Inc., 1120 Veteran Blvd, South San Francisco, CA, 94080, USA
| | - Sandeep Inamdar
- Amgen Inc., 1120 Veteran Blvd, South San Francisco, CA, 94080, USA
| | - Chris Morris
- Amgen Inc., 1120 Veteran Blvd, South San Francisco, CA, 94080, USA
| | - Ying Ou
- Amgen Inc., 1120 Veteran Blvd, South San Francisco, CA, 94080, USA.
| | - Martin Gyger
- Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC H3T 1E2, Canada
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14
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High Cut-Off Hemodialysis for Myeloma Cast Nephropathy – Do We Finally Have An Answer? ACTA ACUST UNITED AC 2017. [DOI: 10.5301/jo-n.5000018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Finkel KW, Cohen EP, Shirali A, Abudayyeh A. Paraprotein-Related Kidney Disease: Evaluation and Treatment of Myeloma Cast Nephropathy. Clin J Am Soc Nephrol 2016; 11:2273-2279. [PMID: 27526708 PMCID: PMC5142056 DOI: 10.2215/cjn.01640216] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nearly 50% of patients with multiple myeloma develop renal disease, most commonly from AKI caused by cast nephropathy. Development of AKI is associated with poor 1-year survival and reduces the therapeutic options available to patients. There is a great need for more effective therapies. Cast nephropathy is caused by the interaction and aggregation of filtered free light chains and Tamm-Horsfall protein causing intratubular obstruction and damage. The key to treating cast nephropathy is rapid lowering of free light chains, because this correlates with renal recovery. Newer chemotherapy agents rapidly lower free light chains and have been referred to as renoprotective. There is additional great interest in using extracorporeal therapies to remove serum free light chains. Small trials initially showed benefit of therapeutic plasma exchange to improve renal outcomes in cast nephropathy, but a large randomized trial of therapeutic plasma exchange failed to show benefit. A newer technique is extended high-cutoff hemodialysis. This modality uses a high molecular weight cutoff filter to remove free light chains. To date, trials of high-cutoff hemodialysis use in patients with cast nephropathy have been encouraging. However, there are no randomized trials showing the benefit of high-cutoff hemodialysis when used in addition to newer chemotherapeutic regimens. Until these studies are available, high-cutoff hemodialysis cannot be recommended as standard of care.
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Affiliation(s)
- Kevin W. Finkel
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas
- Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric P. Cohen
- Nephrology Section, Baltimore Veterans Affairs Medical Center, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Anushree Shirali
- Department of Medicine, Section of Nephrology, Yale University Medical School, New Haven, Connecticut
| | - Ala Abudayyeh
- Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Laforet M, Jourde-Chiche N, Haddad F, Sallee M, Stoppa AM, Brunet P, Dussol B, Burtey S, Gondouin B. Evolution in the treatment of multiple myeloma and impact on dialysis independence: data from a French cohort from 1999 to 2014. Blood Cancer J 2016; 6:e409. [PMID: 27015286 PMCID: PMC4817100 DOI: 10.1038/bcj.2016.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- M Laforet
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France
| | - N Jourde-Chiche
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
| | - F Haddad
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France
| | - M Sallee
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
| | - A M Stoppa
- Department of Hematology, Institut Paoli Calmette, Marseille, France
| | - P Brunet
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
| | - B Dussol
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
| | - S Burtey
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
| | - B Gondouin
- Centre de Nephrologie et Transplantation Rénale, Hopital La Conception, Marseille, France.,Vascular Research Center of Marseille, Faculté de Pharmacie, Aix-Marseille Université, Marseille, France
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17
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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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18
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Shi H, Chen Z, Xie J, Chen N. The Prevalence and Management of Multiple Myeloma-Induced Kidney Disease in China. KIDNEY DISEASES 2016; 1:235-40. [PMID: 27536683 DOI: 10.1159/000443492] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 12/18/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple myeloma (MM) is a clonal B-cell malignancy of the bone marrow. Renal impairment is a common complication of MM. So far, there is no systematic overview of MM-induced kidney disease in China. SUMMARY The incidence of MM is 0.6/100,000 in China. Twenty-four, 19.7, and 30.8% of all patients with MM had renal insufficiency [defined by serum creatinine (Scr) ≥2 mg/dl] at diagnosis in China mainland, Hong Kong and Taiwan, respectively. Novel criteria based on the estimated glomerular filtration rate measurements are recommended for the assessment of renal function in patients with MM with stabilized Scr. It is reported that 78% of the MM patients had a creatinine clearance rate (Ccr) <90 ml/min, and 30.5% had a Ccr <30 ml/min. The IgG type was the most prevalent in MM patients; the light-chain and IgD type usually had a higher rate of kidney damage than others. New more effective drugs, blood purification technology and peripheral blood autologous stem cell transplantation have been introduced in clinical practice. Unfortunately, the studies conducted in the patients with renal insufficiency were almost all retrospective, had a small sample size and a short follow-up time. Although new treatments such as bortezomib are more widely used than before, traditional chemotherapy is still used, also because of economic constraints. The RIFLE criteria, which seem to be appropriate to define the severity of acute kidney injury (AKI), have been extensively validated worldwide but rarely in patients with MM. It was the first time to apply the RIFLE system to analyze the natural history of MM patients with AKI retrospectively in our unit. The severity of AKI defined by using the RIFLE criteria (OR = 2.04, p = 0.06) was associated with a marginal better long-term outcome. KEY MESSAGES Novel criteria of renal insufficiency should be introduced into practice when treating MM. The treatment of MM patients with kidney disease has been greatly improved recently. It is necessary to conduct further large randomized controlled trials of the long-term outcome in China. FACTS FROM EAST AND WEST (1) An Scr level >2 mg/dl has been reported in 16, 21, 24, and 33% of patients with MM in cohort studies of Japan, Europe, China, and Korea, respectively. A Ccr <30 ml/min was observed in 30 and 15% of patients in Chinese and Western MM cohorts, respectively. The commonest cause of severe renal impairment (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 free light chain by high cutoff 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)
- Hao Shi
- Department of Nephrology, Ruijin Hospital, and Institute of Nephrology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zijin Chen
- Department of Nephrology, Ruijin Hospital, and Institute of Nephrology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyuan Xie
- Department of Nephrology, Ruijin Hospital, and Institute of Nephrology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, and Institute of Nephrology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Rousseau-Gagnon M, Agharazii M, De Serres SA, Desmeules S. Effectiveness of Haemodiafiltration with Heat Sterilized High-Flux Polyphenylene HF Dialyzer in Reducing Free Light Chains in Patients with Myeloma Cast Nephropathy. PLoS One 2015; 10:e0140463. [PMID: 26466100 PMCID: PMC4605760 DOI: 10.1371/journal.pone.0140463] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/25/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In cases of myeloma cast nephropathy in need of haemodialysis (HD), reduction of free light chains using HD with High-Cut-Off filters (HCO-HD), in combination with chemotherapy, may be associated with better renal recovery. The aim of the present study is to evaluate the effectiveness of haemodiafiltration (HDF) in reducing free light chain levels using a less expensive heat sterilized high-flux polyphenylene HF dialyzer (HF-HDF). METHODS In a single-centre prospective cohort study, 327 dialysis sessions were performed using a 2.2 m2 heat sterilized high-flux polyphenylene HF dialyzer (Phylther HF22SD), a small (1.1m2) or large (2.1 m2) high-cut-off (HCO) dialyzer (HCOS and HCOL) in a cohort of 16 patients presenting with dialysis-dependent acute cast nephropathy and elevated free light chains (10 kappa, 6 lambda). The outcomes of the study were the mean reduction ratio (RR) of kappa and lambda, the proportion of treatments with an RR of at least 0.65, albumin loss and the description of patient outcomes. Statistical analysis was performed using linear and logistic regression through generalized estimating equation analysis so as to take into account repeated observation within subjects and adjust for session duration. RESULTS There were no significant differences in the estimated marginal mean of kappa RR, which were respectively 0.67, 0.69 and 0.70 with HCOL-HD, HCOS-HDF and HF-HDF (P = 0.950). The estimated marginal mean of the proportions of treatments with a kappa RR ≥0.65 were 68%, 63% and 71% with HCOL-HD, HCOS-HDF and HF-HDF, respectively (P = 0.913). The estimated marginal mean of lambda RR were higher with HCOL-HDF (0.78), compared to HCOL-HD and HF-HDF (0.62, and 0.61 respectively). The estimated marginal mean proportion of treatments with a lambda RR ≥0.65 were higher with HCOL-HDF (81%), compared to 57% in HF-HDF (P = 0.042). The median albumin loss were 7, 21 and 63 g/session with HF-HDF, HCOL-HD and HCOL-HDF respectively (P = 0.044). Among survivors, 9 out of 10 episodes of acute kidney injuries became dialysis-independent following a median time of renal replacement therapy of 40 days (range 7-181). CONCLUSION Therefore, in patients with acute dialysis-dependent myeloma cast nephropathy, in addition to chemotherapy, HDF with a heat sterilized high-flux polyphenylene HF dialyzer could offer an alternative to HCO dialysis for extracorporeal kappa reduction with lower albumin loss.
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Affiliation(s)
- Mathieu Rousseau-Gagnon
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Mohsen Agharazii
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
| | - Sacha A. De Serres
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Simon Desmeules
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
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20
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Rekhtina IG, Zakharova EV, Stolyarevich ES, Sinitsina MN, Denisova EN. [The concurrence of light-chain deposition disease, AL-amyloidosis, and cast nephropathy in a patient with multiple myeloma]. TERAPEVT ARKH 2015; 87:98-101. [PMID: 26281203 DOI: 10.17116/terarkh201587698-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite of the fact that their clinical manifestations are similar, AL-amyloidosis (AL-A) and light chain deposition disease (LCDD) are individual nosological entities in view of considerable differences in their pathogenesis and pathomorphology. The paper describes a rare case of the concurrence of LCDD and AL-A in a patient with multiple myeloma. Clinically, there was dialysis-dependent renal failure, flail leg syndrome, myocardiopathy, and rhabdomyolysis. At the disease onset, his nephrobiopsy specimen could diagnose LCDD and myeloma or cast nephropathy. The disease was characterized by an aggressive course. Despite the administration of innovative agents, the patient had a short-term remission and died from disease progression. Autopsy additionally revealed amyloid deposition in the heart and kidney. The development of AL-A in the presence of prior LCDD may reflect the progression of the tumor and the appearance of an additional subclone of plasma cells that produce amyloidogenic light chains. The uncommonness of this case is that renal amyloid was found in the tubular casts and absent in the glomeruli, which may be considered as a special form--tubular AL-amyloidosis.
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Affiliation(s)
- I G Rekhtina
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - E V Zakharova
- S.P. Botkin City Clinical Hospital, Moscow Healthcare Department, Moscow, Russia
| | - E S Stolyarevich
- Department of Nephrology, Faculty of Postgraduate Education, A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - M N Sinitsina
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - E N Denisova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
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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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Shi H, Zhang W, Li X, Ren H, Pan X, Chen N. Application of RIFLE criteria in patients with multiple myeloma with acute kidney injury: a 15-year retrospective, single center, cohort study. Leuk Lymphoma 2013; 55:1076-82. [DOI: 10.3109/10428194.2013.820284] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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