Management options for cast nephropathy in multiple myeloma:

Predictors of health-related quality of life of the patients treated for MM: the first study in the Palestinian healthcare system

Little studies were conducted to assess the health -related quality of life (HR-QoL) of patients with multiple myeloma (MM) in developing and resource-limited countries. This study assessed the HR-QoL of patients with MM who received treatment in the Palestinian healthcare system as an example of healthcare systems in developing and resource-limited countries. Predictors of deteriorated HR-QoL of the affected patients were also identified. In this cross-sectional study, the tool was a questionnaire that collected the demographic and disease variables of the patients. The questionnaire also contained the EORTC QLQ-MY24 items. The questionnaire was piloted to ensure readability, clarity, and comprehensibility. Additionally, the test-retest reliability and internal consistency were also assessed. In this study, 45.5% of patients with MM who were treated in the Palestinian healthcare system returned usable questionnaires. The mean age of the patients was 60.7 ± 7.5 years and the mean time elapsed since diagnosis was 2.6 ± 1.7 years. Of the patients, 54.3%, 47.8%, 46.7%, 66.3%, 46.7%, and 46.7% reported frequent bone pain, pain that increased with activity, back pain, feeling ill, lost hair, and feeling restless or agitated, respectively. Higher disease symptom scores were predicted by low self-rated satisfaction with the ability to do daily life activities and low self-rated satisfaction with overall health. The side effects of treatment scores were predicted by longer time elapsed since diagnosis and low self-rated satisfaction with overall health. Future perspective scores were predicted by low self-rated satisfaction with overall health. On the other hand, social support scores were predicted by having a university education and not receiving radiotherapy. Patients with MM who were treated in the Palestinian healthcare system reported a heavy burden of disease symptoms, treatment adverse effects, and dissatisfaction with the information they received about their disease. The findings reported in this study are informative to hemato-oncologists and other healthcare providers who care for patients with MM in Palestine and other developing and resource-limited countries. Policymakers might use the findings reported in this study to design interventions to improve the HR-QoL of the patients.

Real world analysis of high-cut-off (HCO) hemodialysis with bortezomib-based backbone therapy in patients with multiple myeloma and acute kidney injury

BACKGROUND

In patients with multiple myeloma (MM) free light chain-induced cast nephropathy is a serious complication associated with poor survival. High-cut-off (HCO) hemodialysis can reduce the amount of serum free light chains (sFLC), but data on its impact on clinical outcome is limited and contradictory. To gain further insights we collected real world data from two major myeloma and nephrology centers in Austria and the Czech Republic.

METHODS

Sixty-one patients with MM and acute kidney injury, who were treated between 2011 and 2019 with HCO hemodialysis and bortezomib-based MM therapy, were analyzed.

RESULTS

The median number of HCO hemodialysis sessions was 11 (range 1-42). Median glomerular filtration rate at diagnosis was 7 ± 4.2 ml/min/1.73m². sFLC after the first HCO hemodialysis decreased by 66.5% and by 89.2% at day 18. At 3 and 6 months, 26 (42.6%) and 30 (49.2%) of patients became dialysis-independent.

CONCLUSION

The widely used strategy combining HCO hemodialysis and bortezomib-based antimyeloma treatment is dissatisfactory for half of the patients undergoing it and clearly in need of improvement.

Early use of PEPA dialyzer for light chains removal and for the recovery from myeloma cast nephropathy: A case report

Chemotherapy and extracorporeal treatment reduce serum free light chains (FLCs) allowing the recovery of acute kidney injury (AKI) caused by myeloma cast nephropathy (MCN). We report the first case of recovery from AKI in a patient with MCN who underwent the removal of FLCs using the PEPA filter, with an undisclosed cut-off, combined with chemotherapy for multiple myeloma (MM).

The treatment of paraprotein-related kidney disease

PURPOSE OF REVIEW

Myeloma kidney and amyloid light-chain (AL) amyloidosis remain the principal kidney complications of paraproteins. In this review, we update readers to many of the recent advances which have occurred in the care and outcomes for patients with these presentations.

RECENT FINDINGS

Myeloma kidney has historically caused a severe acute kidney injury with very poor outcomes. The combination of new diagnostic techniques, enabling a rapid diagnosis and novel chemotherapy agents has transformed these poor outcomes for the better. Two multicentre randomized controlled trials have recently evaluated if the removal of free light chains by high cut-off haemodialysis improves renal outcomes beyond effective chemotherapy alone. Although we await the full articles of these studies to be published, abstracts suggested the studies will have contradictory primary results. In the field of AL amyloidosis, there are now novel criteria for the risk stratification of kidney outcomes which can be used in combination with markers of early kidney response to provide clinicians with powerful tools to guide patient discussions.

SUMMARY

Across both AL amyloidosis and myeloma kidney patient outcomes continue to improve. Principally this improvement has been driven by the continuing development of novel chemotherapy agents in this field.

Renal Involvement in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence. The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.

Current Trends of Renal Impairment in Multiple Myeloma

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.

Lenalidomide and dexamethasone for acute light chain-induced renal failure: a phase II study

We prospectively evaluated the activity and tolerance of lenalidomide-dexamethasone in 35 patients with acute light chain-induced renal failure. The lenalidomide dose was adapted to the estimated glomerular filtration rate and dexamethasone was given at high dose in cycle one and at low dose thereafter. Four patients died within the first two cycles, and five discontinued therapy leaving 26 patients for the per-protocol analysis. Responses were observed in 24/35 (68.6%) patients of the intent-to-treat population. Complete response was noted in seven patients (20%), very good partial response in three patients (8.6%), partial response in 14 patients (40%), and minimal response in one patient (2.9%). Renal response was observed in 16 (45.7%) patients: five (14.2%) achieved complete, four (11.4%) partial and seven (20%) minor renal responses. Five of 13 patients who were dialysis dependent at baseline became dialysis independent. The median time to myeloma and to renal response was 28 days for both parameters, while the median time to best myeloma and best renal response was 92 and 157 days, respectively. The median estimated glomerular filtration rate increased significantly in patients with partial response or better from 17.1 mL/min at baseline to 39.1 mL/min at best response (P=0.001). The median progression-free and overall survival was 5.5 and 21.8 months, respectively, in the intent-to-treat population and 12.1 and 31.4 months, respectively, in the per-protocol group. Infections, cardiotoxicity, anemia and thrombocytopenia were the most frequent toxicities. In conclusion, the lenalidomide-dexamethasone regimen achieved rapid and substantial myeloma and renal responses. The trial was registered under EUDRACT number 2008-006497-15.

Polymethylmethacrylate membrane and serum free light chain removal: enhancing adsorption properties

INTRODUCTION

Polymethylmethacrylate (PMMA) membranes can adsorb a wide variety of uremic toxins including serum free light chains (sFLC). However, limited data are available regarding the clinical use of PMMA in multiple myeloma patients and its maximum adsorption capacity in this setting.

AIM

This study aimed to measure the capacity of PMMA to adsorb sFLC and identify strategies to improve its efficiency in clinical practice.

METHODS

Ten patients with dialysis-dependent renal failure and high levels of sFLC were included in the study. Five patients received standard PMMA hemodialysis (HD; n = 18), while in the other 5 patients a new technique called enhanced adsorption dialysis (EAD) was used, which involves PMMA dialyzer replacement after 2 h (n = 19). In all patients, sFLC were measured at the beginning and at the end of each dialysis session to calculate the difference between start and end of treatment and the percentage removal.

RESULTS

PMMA membranes reduced sFLC in both the PMMA HD and EAD groups. PMMA HD showed similar efficiency on κ and λ percentage removal (22.3 and 21.0%, respectively, n.s.) but, in contrast, had a significantly greater effect on the delta of sFLC in κ [1,555 mg/l (-511 to +6,027)] versus λ [390 mg/l (120-650)] treatments (p = 0.007). EAD treatments only partially increased percentage removal of κ sFLC (22.3-31.0%, p = 0.38), while they had a significantly great effect on λ (21.0-53.1%, p = 0.003). A positive linear correlation was found between delta sFLC and pre-HD sFLC concentrations in PMMA HD κ treatments (r = 0.68, p < 0.02) but not for λ treatments (r = 0.54, p = 0.21), while the analysis of patients receiving EAD demonstrated a strong positive correlation for both κ and λ subtypes (r = 0.81 and r = 0.85, respectively, p < 0.008). In EAD sessions, a positive linear correlation was shown between blood flow during treatment and percentage removal of sFLC (r = 0.58, p = 0.02); however, with PMMA HD such a correlation was not observed (r = 0.28, p = 0.25).

CONCLUSIONS

PMMA membranes can efficiently adsorb sFLC, but the process is limited by membrane saturation and is different between κ and λ sFLC. The new EAD technique can greatly improve λ removal but only partially act on κ sFLC. Therefore, EAD should be considered a valid economic treatment option without side effects in particular subsets of patients for the removal of sFLC.

The role of immunological assessment in patients with acute kidney injury and possible myeloma

Acute kidney injury (AKI) in plasma cell multiple myeloma (MM) is a medical emergency requiring a rapid, accurate diagnosis because prompt commencement of therapy and supportive care are essential. Most cases of AKI in MM are caused by cast nephropathy secondary to high levels of nephrotoxic serum free light chains (FLCs). This article reviews the role and relevance of FLC as an immunological biomarker for AKI and MM. We discuss the utility of FLC measurement as a screening tool in the cast nephropathy clinical setting. We present its analytical pitfalls and evolving evidence for the integration of an FLC assay into clinical algorithms.

Achieving an early myeloma response in patients with kidney impairment

There is increasing evidence, particularly in severe acute kidney injury, that treatment of multiple myeloma with regimens that include dexamethasone in combination with novel chemotherapy agents are associated with an early disease response in most patients. However, the evidence to guide the optimal chemotherapy regimen in patients with kidney impairment is limited, and treatment choices are complicated by the effect of kidney function on drug dosing. Here, we summarize the current status of this field, with a particular focus on chemotherapy regimens that are based on dexamethasone and novel agents and an outline of those areas in which further work is needed to improve the evidence base.

Monoclonal gammopathy of undetermined significance: an update for nephrologists

Screening for a monoclonal protein is a common part of the assessment of patients presenting with a renal injury. While in the settings of acute kidney injury, chronic kidney disease and proteinuria monoclonal proteins can be associated with significant pathologies such as cast nephropathy, amyloidosis, and light chain deposition disease, they can also be an unrelated finding. The purpose of this review is to provide the nephrologist with an update to the diagnostic assessment and risk stratification of monoclonal proteins to avoid unnecessary investigation and monitoring of those patients with low-risk monoclonal gammopathies.

Myeloma kidney: improving clinical outcomes?

Renal impairment is a common complication of multiple myeloma, affecting 20% to 40% of new cases (depending on the definition). Most cases are mild and easily reversible, but it may manifest as severe acute renal injury requiring dialysis. Renal impairment is associated with a large tumor mass and consequently confers a poor prognosis. The prognosis of myeloma has improved with the introduction of novel agents and autologous stem cell transplantation. These improvements appear to apply equally to patients with renal impairment, although the risk of complication is usually higher in this group of patients. In addition to improved overall survival, there is some evidence that novel therapies have improved the renal prognosis. Treatment with high-dose dexamethasone and bortezomib can rapidly reduce light chain production and provide an opportunity for renal recovery. Although trials of plasma exchange (to remove the nephrotoxic light chain) have shown a disappointing lack of benefit, high cutoff dialysis removes larger quantities of light chain; therefore, trials are underway to investigate whether this can improve the renal prognosis independently of chemotherapy. Outcomes in patients with myeloma kidney do appear to be improving, but more trials are needed (some of which are in progress). There is cause for optimism for physicians and for patients suffering from this condition.

Cast nephropathy and light-chain deposition disease in Waldenström macroglobulinemia

Waldenström macroglobulinemia is a rare low-grade hematologic malignancy due to clonal proliferation of B lymphocytes responsible for immunoglobulin M (IgM) monoclonal gammopathy secreted in serum. This disease is characterized by lymphoplasmacytic tumoral infiltration of bone marrow and various organs, especially the liver and spleen. Kidney involvement in Waldenström macroglobulinemia has been described previously with reports of various forms of glomerular injury: large intracapillary IgM pseudothrombi, cryoglobulinemia-associated membranoproliferative glomerulonephritis, or amyloidosis. Interstitial infiltration by tumoral B lymphocytes is another classic pattern. Conversely, tubular involvement in the form of myeloma-like casts or basement membrane deposition of monoclonal light chain (light-chain deposition disease) is unusual. We report the occurrence of cast nephropathy associated with light-chain deposition disease in 2 patients with Waldenström macroglobulinemia, which resulted in severe and prolonged kidney failure.

Evaluation of multiple myeloma patients presenting with renal failure in a university hospital in the year 2010

BACKGROUND

The aim of this cross-sectional study was to evaluate multiple myeloma patients presenting with renal failure in a University hospital.

METHODS

The records of all the patients diagnosed with multiple myeloma in the departments of hematology and nephrology at Gazi University Hospital between January 2010 and January 2011 were reviewed retrospectively. Renal failure was defined as a serum creatinine level of ≥2 mg/dL. Median age was 63 (range 37-80) years, with 13 male and 17 female patients.

RESULTS

Eight (26.7%) of the 30 patients had renal failure and 4 (50%) patients with renal failure required renal replacement therapy with hemodialysis after admission. Renal functions recovered in four (50%) of the eight patients after treatment. In one of the eight patients (12.5%) creatinine levels improved, but did not reach the level defined as reversal of renal failure. The renal functions of the three (37.5%) patients did not improve and they remained on chronic hemodialysis program during which one of them died due to a cerebrovascular accident and one other patient was lost due to follow-up.

CONCLUSION

A substantial proportion of myeloma patients referred with renal failure might enjoy a disease-free survival and could be saved from chronic renal replacement therapy with prompt diagnosis and treatment in the era of new-generation anti-myeloma agents which provide fast and effective responses. Multiple myeloma should be considered in the differential diagnosis of acute renal failure even in the absence of hyperglobulinemia and hypercalcemia.

The pathogenesis and diagnosis of acute kidney injury in multiple myeloma

Renal failure remains a principal cause of morbidity for patients with multiple myeloma. Once reversible factors such as hypercalcemia have been corrected, the most common cause of severe renal failure in these patients is a tubulointerstitial pathology that results from the very high circulating concentrations of monoclonal immunoglobulin free light chains. These endogenous proteins can result in isolated proximal tubule cell cytotoxicity, tubulointerstitial nephritis and cast nephropathy (myeloma kidney). Less frequently, high levels of free light chains can lead to immunoglobulin light chain amyloidosis and light chain deposition disease, although these conditions are usually associated with insidious progression of renal failure rather than acute kidney injury. Unless there is rapid intervention, progressive and irreversible damage occurs, particularly interstitial fibrosis and tubular atrophy. Despite advances in our understanding of the pathogenesis of these processes there has been a gap in translating these achievements into improved patient outcomes. The International Kidney and Monoclonal Gammopathy Research Group was formed to address this need. In this Review, we discuss the mechanisms of disease and diagnostic approaches to patients with acute kidney injury complicating multiple myeloma.

Recent advances in the pathogenesis and management of cast nephropathy (myeloma kidney)

Multiple myeloma is an incurable plasma cell malignancy that is often accompanied by renal failure; there are a number of potential causes of this, of which cast nephropathy is the most important. Renal failure is highly significant in myeloma, as patient survival can be stratified by the severity of the renal impairment. Consequently, there is an ongoing focus on the pathological basis of cast nephropathy and the optimal treatment regimens in this setting, including effective chemotherapy regimens to reduce light chain production and emerging extracorporeal techniques to remove circulating light chains. This paper bridges recent advances in the pathogenesis and management of cast nephropathy in multiple myeloma.

Online high-efficiency haemodiafiltration achieves higher serum free light chain removal than high-flux haemodialysis in multiple myeloma patients: preliminary quantitative study

BACKGROUND

Fast reduction of serum free light chain (FLC) levels correlate with renal recovery in cast nephropathy. Because convection has the capacity to remove proteins of higher molecular weights, we hypothesized that haemodiafiltration (HDF) would be superior to haemodialysis (HD) for FLC clearance.

METHODS

We retrospectively identified all renal replacement therapy (RRT) sessions performed in multiple myeloma patients with pre- and post-treatment FLC measurements during a 2-year period. Using kinetic modelling, we calculated reduction percentages corrected for net ultrafiltration, effective clearances, net mass removal and Kt/V for both kappa (κ) and lambda (λ) serum FLC.

RESULTS

We analysed 27 (10 HD and 17 HDF) RRT sessions realized in a total of six subjects. HDF resulted in higher FLC removal rates when compared to HD. Moreover, high-efficiency (i.e. substitution volume > 15 L/session) HDF demonstrated median efficient FLC clearances roughly twice superior to high-flux HD for both κ (59.0 versus 33.8 mL/min, respectively; P < 0.01) and λ (40.5 versus 19.7 mL/min, respectively; P = 0.02) FLC. In post-dilution HDF treatments, corrected FLC reduction percentages positively correlated with substitution volumes. Total plasma proteins increased during RRT in the HDF group.

CONCLUSIONS

This preliminary quantitative study demonstrates the superiority of high-efficiency HDF over high-flux HD for serum FLC removal in multiple myeloma patients on RRT. No negative impact on total plasma proteins was noted.