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Toprak Z, Ersoy Yesil E, Zerenler Gursoy F, Keski H, Kayabasi H, Sit D, Kucuk EV. A Case of Primary Renal Allograft Dysfunction Caused by Missed Monoclonal Disease. EXP CLIN TRANSPLANT 2024; 22:572-575. [PMID: 39223816 DOI: 10.6002/ect.2023.0155] [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: 09/04/2024]
Abstract
We present an unusual etiology of primary renal allograft dysfunction attributed to myeloma cast nephropathy in a patient with no history of multiple myeloma before kidney transplant. The patient, a 54-year-old woman, had been on hemodialysis for 6 months before transplant for presumed diabetic nephropathy; she developed graft dysfunction immediately after transplant. Graft biopsy specimens were consistent with myeloma cast nephropathy, and she was treated with bortezomib, cyclophosphamide, and dexamethasone. She achieved a complete hematological response and regained excellent graft function 3 months after transplant. The patient then received autologous stem cell transplant 8 months after kidney transplant. To our knowledge, this is the second report of a successful graft outcome after chemotherapy and the first report treated with autologous stem cell transplantation after remission of monoclonal disease.
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Affiliation(s)
- Zeki Toprak
- >From the Department of Nephrology, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
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2
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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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Dykes K, Desale S, Javaid B, Miatlovich K, Kessler C. A New Reality for Multiple Myeloma Renal Failure: US Data Report on Kidney Transplant Outcomes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e314-e320. [PMID: 34872880 DOI: 10.1016/j.clml.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Describe graft and overall survival outcomes in multiple myeloma (MM) patients who underwent kidney transplant (KT) compared to the general KT population. PATIENTS AND METHODS The Organ Procurement and Transplantation Network/National United Network for Organ Sharing (OPTON/UNOS) database was analyzed from 1988 to 2019 with R 4.00 and the 2013-2017 United States Renal Data System (USRDS) was surveyed for incidence and mortality of MM ESRD. RESULTS USRDS analysis revealed 961 patients diagnosed with ESRD due to MM on average annually, accounting for 0.8% of the ESRD population. Without KT, 44.4% of MM patients died in the first year of renal replacement initiation. OPTON/UNOS analysis identified 218 MM KT patients, compared to 490,089 patients without MM. There was no difference in graft survival between MM KT and the general population (P-value = .13, HR = 1.19 [0.95, 1.49], 95% CI). Median graft survival in MM KT was 2683 days (7.4 years). KT patients with MM had a higher risk for death (P-value = <.0001, HR = 1.83 [1.41, 2.37], 95% CI), and median overall survival was 3076 days (8.4 years). Survival difference was lost when comparing patients ≥50 years (P-value = .42, HR = 1.14 [0.83, 1.56], 95% CI). CONCLUSION Patients with MM renal failure who underwent KT had equivalent graft and age-matched overall survival compared to the general KT population. Therefore select patients with MM renal failure have potential for excellent KT outcomes, should be considered for transplantation when feasible, and should not be excluded from KT based on a history of MM.
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Affiliation(s)
- Kaitlyn Dykes
- MedStar Georgetown University Hospital Internal Medicine, Washington, DC.
| | - Sameer Desale
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, MD
| | - Basit Javaid
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Krystsina Miatlovich
- Institute of Business and Management of Technologies, Belarusian State University, Minsk, Belarus
| | - Craig Kessler
- MedStar Georgetown Lombardi Comprehensive Cancer Center, Washington, DC
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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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Dinh AR, Wong SW, Martin TG, Wolf JL, Webber AB. Outcomes of kidney transplant recipients with ESKD due to plasma cell dyscrasia: A case series. Clin Transplant 2021; 36:e14541. [PMID: 34797567 DOI: 10.1111/ctr.14541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
Transplant centers have historically been reluctant to proceed with kidney transplantation in individuals with plasma cell dyscrasias (PCDs) due to concern for high rates of PCD recurrence and PCD-related mortality. As novel therapies for PCDs have improved hematologic outcomes, strategies to optimize kidney transplantation in individuals with PCD-mediated kidney disease are needed. In this single-center case series we discuss our protocol for the transplantation of individuals with ESKD attributed to PCD as well as the hematologic and allograft outcomes of 12 kidney transplant recipients with ESKD attributed to PCD. Median follow-up time after kidney transplantation was 44 months (IQR 36, 84). All patients had a functioning allograft 1 year after kidney transplantation. 9/12 patients were alive and had a functioning allograft 5 years after kidney transplantation. Five patients experienced relapse of PCD (of whom three responded well to subsequent therapies) and four patients developed secondary malignancies, including three patients with urologic malignancies. This case series demonstrates that patients with kidney disease attributed to PCD have favorable outcomes with kidney transplantation. Transplant evaluation in patients with PCDs should involve a multidisciplinary team of transplant nephrologists and oncologists to select appropriate candidates. Providers should consider screening for urologic malignancies pre- and post-transplantation.
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Affiliation(s)
- Alex R Dinh
- Department of Medicine, Division of Nephrology, University of California, San Francisco, California, USA.,Department of Medicine, Kidney Transplant Service, University of California, San Francisco, California, USA
| | - Sandy W Wong
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Thomas G Martin
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Jeffrey L Wolf
- Department of Medicine, Division of Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco, California, USA
| | - Allison B Webber
- Department of Medicine, Division of Nephrology, University of California, San Francisco, California, USA.,Department of Medicine, Kidney Transplant Service, University of California, San Francisco, California, USA
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6
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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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Bridoux F, Leung N, Belmouaz M, Royal V, Ronco P, Nasr SH, Fermand JP. Management of acute kidney injury in symptomatic multiple myeloma. Kidney Int 2021; 99:570-580. [PMID: 33440212 DOI: 10.1016/j.kint.2020.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Symptomatic multiple myeloma is commonly complicated by acute kidney injury through various mechanisms. The most frequent is the precipitation of monoclonal free light chains with uromodulin in the distal tubules, defining light chain cast nephropathy. Early diagnosis and identification of the cause of acute kidney injury are required for optimizing management and avoiding chronic kidney injury that strongly affects quality of life and patient survival. In light chain cast nephropathy, often manifesting with severe acute kidney injury, renal recovery requires urgent intervention based on vigorous rehydration, correction of precipitating factors, and efficient anti-plasma cell chemotherapy to rapidly reduce the secretion of nephrotoxic free light chains. Currently, the association of the proteasome inhibitor bortezomib with high-dose dexamethasone is the standard regimen in newly diagnosed patients. The addition of another drug such as cyclophosphamide or an immunodulatory agent may improve free light chain response but raises tolerance concerns in frail patients. Further studies are warranted to confirm the role of anti-CD38 monoclonal antibodies, whose efficacy and tolerance have been documented in patients without renal impairment. Despite controversial results from randomized studies, recent data suggest that in patients with light chain cast nephropathy and acute kidney injury requiring dialysis, the combination of chemotherapy with free light chain removal through high-cutoff hemodialysis may increase renal response recovery rates. Kidney biopsy may be helpful in guiding management and assessing renal prognosis that appears to depend on the extent of cast formation and interstitial fibrosis/tubular atrophy. Because of continuous improvement in life expectancy of patients with multiple myeloma, renal transplantation is likely to be increasingly considered in selected candidates.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Belmouaz
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Pierre Ronco
- Nephrology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France; Sorbonne Université and Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Mixte de Recherche S 1135, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France; Intergroupe Francophone du Myélome (IFM), Paris, France
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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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9
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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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10
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Kormann R, Pouteil-Noble C, Muller C, Arnulf B, Viglietti D, Sberro R, Sayegh J, Durrbach A, Dantal J, Girerd S, Pernin V, Albano L, Rondeau E, Peltier J. Kidney transplantation for active multiple myeloma or smoldering myeloma: a case- control study. Clin Kidney J 2019; 14:156-166. [PMID: 33564414 PMCID: PMC7857822 DOI: 10.1093/ckj/sfz128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/20/2019] [Indexed: 12/22/2022] Open
Abstract
Background The increased survival of patients with multiple myeloma (MM) raises the question of kidney transplantation (KT) in patients with end-stage renal disease (ESRD). Methods We included 13 patients with MM or smoldering myeloma (SMM) and ESRD transplanted between 2007 and 2015, including 7 MM with cast nephropathy, 3 with MM-associated amyloid light chain amyloidosis or light chain deposition disease and 3 SMM and compared them with 65 control-matched kidney-transplanted patients. Nine of the MM patients with KT were also compared with 63 matched MM patients on haemodialysis. Results Pre-transplantation parameters were comparable, except for the duration of renal replacement therapy (57.8 versus 37.0 months; P = 0.029) in MM versus control patients, respectively. The median follow-up post-KT was 44.4 versus 36.4 months (P = 0.40). The median MM graft and patient survival were 80.1 and 117.2 months, respectively, and were not significantly different from control patients, although mortality tended to be higher in the 10 symptomatic MM patients (P = 0.059). MM patients had significantly more viral and fungal infections and immunosuppressive maintenance therapy modifications while they received lower induction therapy. Two MM patients relapsed and two SMM cases evolved to MM after KT. Three cast nephropathies occurred, two of them leading to ESRD. Moreover, survival of MM with KT increased relative to control haemodialysed patients (P = 0.002). Conclusions Selected MM patients may benefit from KT but need careful surveillance in the case of KT complications and MM evolution.
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Affiliation(s)
- Raphaël Kormann
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, AP-HP, Université Pierre et Marie Curie, Paris, France
- Correspondence and offprint requests to: Raphaël Kormann; E-mail:
| | - Claire Pouteil-Noble
- Service de Transplantation-Néphrologie, Hôpital Edouard Herriot and Université Lyon 1, Lyon, France
| | - Clotilde Muller
- Néphrologie-Transplantation, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Bertrand Arnulf
- Service d’Immuno-hématologie, Hôpital Saint Louis, Université Denis Diderot-Paris VII AP-HP, Paris, France
| | - Denis Viglietti
- Service de Néphrologie, Hôpital Saint Louis, Université Denis Diderot-Paris VII AP-HP, Paris, France
| | - Rebecca Sberro
- Service de Transplantation, Hôpital Necker, Université Paris Descartes AP-HP, Paris, France
| | - Johnny Sayegh
- Service de Néphrologie–Dialyse–Transplantation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Antoine Durrbach
- Service de Néphrologie, Hôpital Bicêtre, AP-HP, Inserm UMRS 1197, Université Paris Sud, Paris, France
| | - Jacques Dantal
- Service de Néphrologie et d'Immunologie Clinique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Sophie Girerd
- Service de Néphrologie et Transplantation, Centre Hospitalier Universitaire de Nancy, Vandoeuvre-Les-Nancy, France
| | - Vincent Pernin
- Département de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Laetitia Albano
- Service de Néphrologie et Transplantation Rénale, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Eric Rondeau
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, AP-HP, Université Pierre et Marie Curie, Paris, France
- Néphrologie-Transplantation, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Julie Peltier
- Service d'Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, AP-HP, Université Pierre et Marie Curie, Paris, France
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11
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Lim WH, Au E, Krishnan A, Wong G. Assessment of kidney transplant suitability for patients with prior cancers: is it time for a rethink? Transpl Int 2019; 32:1223-1240. [PMID: 31385629 PMCID: PMC6900036 DOI: 10.1111/tri.13486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/16/2019] [Accepted: 07/31/2019] [Indexed: 12/19/2022]
Abstract
Kidney transplant recipients have up to a 100-fold greater risk of incident cancer compared with the age/sex-matched general population, attributed largely to chronic immunosuppression. In patients with a prior history of treated cancers, the type, stage and the potential for cancer recurrence post-transplant of prior cancers are important factors when determining transplant suitability. Consequently, one of the predicaments facing transplant clinicians is to determine whether patients with prior cancers are eligible for transplantation, balancing between the accelerated risk of death on dialysis, the projected survival benefit and quality of life gains with transplantation, and the premature mortality associated with the potential risk of cancer recurrence post-transplant. The guidelines informing transplant eligibility or screening and preventive strategies against cancer recurrence for patients with prior cancers are inconsistent, underpinned by uncertain evidence on the estimates of the incidence of cancer recurrence and the lack of stage-specific outcomes data, particularly among those with multiple myeloma or immune-driven malignancies such as melanomas. With the advent of newer anti-cancer treatment options, it is unclear whether the current guidelines for those with prior cancers remain appropriate. This review will summarize the uncertainties of evidence informing the current recommendations regarding transplant eligibility of patients with prior cancers.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Eric Au
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Anoushka Krishnan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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12
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Hedvat J, Nair V, Miko L, Menon MC, Santeusanio A. Outcomes of renal transplantation in patients with previous hematologic malignancies. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/2399369319865539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Recommendations regarding the appropriateness of renal transplantation in patients with prior hematologic malignancies are limited. Given the lack of available data, studies are needed to assess which of these patients will maximally benefit from renal transplantation. This study was undertaken to describe the incidence of new or recurrent malignancy as well as patient and allograft survival, acute rejection, and serious infections in patients with prior hematologic malignancies receiving renal transplantation. This was a single center retrospective review of all adult patients with a previous hematologic malignancy who received a living or deceased renal transplantation between January 2009 and January 2016. Eight renal transplantation recipients with prior hematologic malignancies were identified and followed for a minimum of 3 years. Six patients received prior chemotherapy and five had a prior hematopoietic stem cell transplant. Median time from remission to transplant was 2.6 years. Three-year patient and allograft survival were 87% and 75%, respectively. Three patients were diagnosed with new cancers within 3 years post-renal transplantation; one of which died from cancer-related complications with a functioning allograft. There was concern for recurrent hematologic malignancies in two patients based on serologic studies, but, both of these patients were alive with functioning allografts at 3-year follow-up. Our experience suggests that renal transplantation can be successfully performed in select patients with prior hematologic malignancy but with a significant risk for de novo malignancy post-transplant, which may be associated with an overall poor prognosis. Decisions regarding renal transplantation candidacy should be made based on risk stratification and multidisciplinary discussions with patients, hematologists, and transplant providers.
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Affiliation(s)
- Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Vinay Nair
- Division of Nephrology, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Leandra Miko
- Department of Pharmacy, The Mount Sinai Hospital, New York, NY, USA
| | - Madhav C Menon
- Department of Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York, NY, USA
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13
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Shah S, Ibrahim M, Delaney M, Schey S, Bygrave C, Streetly M, Benjamin R. Risk of relapse of multiple myeloma following kidney transplantation. Clin Kidney J 2019; 12:216-223. [PMID: 30976399 PMCID: PMC6452174 DOI: 10.1093/ckj/sfy137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) and novel therapies have improved the prognosis for patients with multiple myeloma (MM). For those who undergo ASCT while on dialysis, a similar survival compared with the overall MM population has been reported. Therefore, for patients achieving remission following ASCT, kidney transplantation is an attractive option, offering an improved quality of life and significant economic advantage. Method This case series investigates the outcome of five patients who underwent an ASCT for MM with subsequent kidney transplantation between 2006 and 2012. Results Four patients presented with end-stage renal disease (ESRD) and one progressed to ESRD shortly after diagnosis. Induction chemotherapy regimens with novel agents including thalidomide and bortezomib were utilized. Following attainment of very good partial remission or complete remission, high-dose melphalan ASCTs were performed after a median of 10 months. Kidney transplantation (living donor n = 3, deceased donor n = 2) with tacrolimus-based immunosuppression regimens was completed at a median of 27 months after ASCT. Patients 1 and 3 experienced relapse of myeloma at 6 and 16 months after kidney transplantation. Patients 2, 4 and 5 remain alive at 55 months (median) after kidney transplantation with no evidence of relapse. Conclusion Forty percent of our cohort experienced a relapse in MM within 2 years of kidney transplantation. Death-censored graft survival and patient survival were 80% at 4 years. Our study adds to the growing literature supporting kidney transplantation following successful ASCT for MM and is useful when counselling patients regarding renal and haematological outcomes.
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Affiliation(s)
| | | | - Michael Delaney
- East Kent Hospital University NHS Foundation Trust, Kent, UK
| | - Steve Schey
- King's College Hospital NHS Trust, London, UK
| | - Ceri Bygrave
- Cardiff and Vale University Health Board, Cardiff, UK
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14
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Van den bosch I, Sprangers B, Gertz M. Multiple myeloma and kidney transplantation: the beginning of a new era. Clin Kidney J 2019; 12:213-215. [PMID: 30976398 PMCID: PMC6452187 DOI: 10.1093/ckj/sfz003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Indexed: 11/13/2022] Open
Abstract
The introduction of several novel therapeutic agents has improved the outcome in multiple myeloma (MM) patients including those with chronic kidney disease, and it is predicted that MM will become a curable disease in a substantial subset of MM patients. While in the past-because of inferior posttransplant outcomes-renal transplantation was not offered to MM patients, recent data suggest that renal transplantation is a viable treatment option in patients treated with modern anti-myeloma induction therapy followed by autologous stem cell transplantation achieving durable complete responses. The article of Shah, Ibrahim, Delaney et al. [Risk of relapse of multiple myeloma following kidney transplantation: a case series report. Clin Kidney J 2018 (in this issue)] in the current issue of Clinical Kidney Journal adds to this evidence and highlights the limitations and outstanding questions concerning renal transplantation in MM patients.
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Affiliation(s)
- Ines Van den bosch
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
- Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
- Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Morie Gertz
- Division of Hematology, Department of Medicine, College of Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Gödecke V, Schmidt JJ, Bräsen JH, Koenecke C, Haller H. [Diagnosis and treatment of kidney involvement in plasma cell diseases : Renal involvement in multiple myeloma and monoclonal gammopathies]. Internist (Berl) 2019; 60:10-22. [PMID: 30635666 DOI: 10.1007/s00108-018-0538-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Kidney involvement is a common complication in patients with plasma cell diseases. OBJECTIVE This article outlines the spectrum of renal involvement in plasma cell dyscrasia and describes diagnostic and therapeutic measures to guide clinical management. MATERIAL AND METHODS Evaluation and discussion of the current literature as well as existing guidelines and recommendations of professional societies. RESULTS The clinical manifestations of renal involvement in plasma cell disorders are heterogeneous and range from acute cast nephropathy in multiple myeloma to rare forms of glomerulonephritis. The term monoclonal gammopathy of renal significance (MGRS) was introduced to describe kidney involvement caused by monoclonal gammopathy but without evidence for underlying malignancy. Light chain cast nephropathy is the most common renal manifestation in multiple myeloma, whereas monoclonal immunoglobulin deposition disease (MIDD) and renal light chain (AL) amyloidosis can be found in multiple myeloma and MGRS. Decisive is the extended hematological diagnostics in order to exclude the presence of a hematological neoplasm. The treatment of renal involvement in monoclonal gammopathies involves the reduction of the plasma cell clone with cytoreductive treatment. The reduction of the monoclonal protein in serum is prognostically relevant for the renal response to treatment. In the case of histological evidence of a light chain cast nephropathy, high cut-off dialysis is recommended to reduce the free light chains in serum. CONCLUSION The spectrum of renal manifestations in plasma cell dyscrasia has been expanded, particularly since the introduction of the term MGRS. Diagnostic and therapeutic management remain an interdisciplinary challenge.
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Affiliation(s)
- V Gödecke
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - J J Schmidt
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - J H Bräsen
- Institut für Pathologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - C Koenecke
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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16
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17
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Kidney Transplantation in Patients With Active Multiple Myeloma: Case Reports. Transplant Direct 2017; 3:e200. [PMID: 28795151 PMCID: PMC5540638 DOI: 10.1097/txd.0000000000000716] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/23/2017] [Indexed: 01/29/2023] Open
Abstract
Kidney disease is a common complication in patients with multiple myeloma. Traditionally, patients with active multiple myeloma and end-stage renal disease have been excluded from kidney transplantation due to the risk of malignancy progression. The introduction of bortezomib-based therapy for patients with multiple myeloma and renal impairment has significantly improved survival in this population. In this report, we present 2 cases of patients with active and controlled multiple myeloma who underwent successful kidney transplantation without progression of their underlying malignancy. In patients with active multiple myeloma controlled with bortezomib, kidney transplantation should be considered a valid option for patients with end-stage kidney disease.
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