[Autologous haematopoietic stem cell transplantation in patients with multiple myeloma complicated by dialysis-dependent renal failure]

AIM

To assess the safety and efficacy of autologous haematopoietic stem cell transplantation (auto-HSCT) in multiple myeloma (MM) patients with dialysis-dependent renal failure.

MATERIALS AND METHODS

During a period from May 2010 to December 2016 fourteen MM patients with dialysis-dependent renal failure aged 48 to 65 years underwent auto-HSCT. After the induction therapy complete response, very good partial response, partial response were documented in 64, 29, 7% of patients, respectively. In no case was a renal response achieved. Haematopoietic stem cell mobilization in most patients (13/14) was performed according to the scheme: G-CSF 10 g/kg. Melphalan in 3 dosages was used as pre-transplant conditioning: 100, 140 and 200 mg/m2; 13 patients underwent a single and in one case underwent a tandem auto-HSCT against the background of hemodialysis. Evaluation of the antitumor and renal response was assessed on the 100th day after auto-HSCT. Subsequently, against the background of programmed hemodialysis and in the setting of high-dosed melphalan (100200 mg/m2), 13 patients underwent a single and one patient underwent a tandem auto-HSCT. At +100 days after auto-HSCT, an antitumor response and renal response were assessed.

RESULTS

The period of agranulocytosis after auto-HSCT was from 5 to 12 days (median 8,5) and was accompanied by infectious complications, cardiac and neurological dysfunctions. At +100 days after auto-HSCT, the complete response was confirmed in 71% patients and very good partial response was confirmed in 29% patients. The minimal renal response was registered in 2 patients (14%), hemodialysis was stopped. The transplant-related mortality was absent. After a median follow-up of 53 months 5-year progression-free survival was 59%, and overall survival was 93%.

CONCLUSION

Carrying out auto-HSCT in patients with dialysis-dependent renal failure contributed to the achievement of a minimal renal response in 14% of cases, which allowed these patients to stop hemodialysis. Patients whose conditioning regimen was performed using melphalan at a dose of 200 mg/m2showed more frequent complications in the early post-transplant period compared to patients who received a lower dose of melphalan (100140 mg/m2). Auto-HSCT in MM patients with dialysis-dependent renal failure is a feasible and effective treatment method, which in some cases contributes to independence from hemodialysis.

[Morphological and immunohistochemical predictors of renal response to therapy patients with myeloma cast nephropathy and dialysis-dependent acute kidney injury]

AIM

Reveal morphological and immunohistochemical predictors of reversibility of dialysis-dependent acute kidney injury (AKI) in patients with myeloma cast nephropathy (MCN) based on the study of kidney biopsy.

MATERIALS AND METHODS

Renal pathological findings were studied in 36 patients with MCN and dialysis-dependent stage 3 AKI (AKIN, 2012). The study of biopsy samples was performed by a semi-quantitative and quantitative analysis using computer morphometry. The expression of E-cadherin, vimentin and-smooth muscle actin was determined immunohistochemically in the tubular cells and interstitium. Induction therapy for 26 patients was carried out to bortezomib-based programs; in 10 patients other schemes were used. A comparative analysis of morphological changes in nephrobiopathy depending on the renal response was performed in patients with achieved hematologic remission.

RESULTS

Improved renal function was observed only in patients with hematologic response to therapy. There were no differences in the number of sclerotic glomeruli, protein casts, the area of inflammatory interstitial infiltration, and the degree of acute tubular damage in patients with and without renal response. In patients with renal response compared with patients without improving renal function, the area of interstitial fibrosis was less (24.9% and 45.9%, respectively;p=0.001), and the area of E-cadherin expression was larger (15.9% and 7.1%, respectively;p=0.006). Interstitial fibrosis of 40% or more and/or the area of expression of E-cadherin less than 10% of the area of tubulo-interstitium have an unfavorable prognostic value in achieving a renal response in MCN.

CONCLUSION

If the interstitial fibrosis area is 40% or more and the expression area of E-cadherin is less than 10%, the probability of the absence of a renal response is 93.3% (OR=24.5) even when a hematological response to induction therapy is achieved. The number of protein casts, the prevalence of acute tubular damage and inflammatory interstitial infiltration have not prognostic value.

CLINICAL IMPORTANCE OF RENAL RECOVER ON OUTCOMES OF NEWLY DIAGNOSED MULTIPLE MYELOMA PATIENTS WITH SEVERE AND DIALYSIS-DEPENDENT KIDNEY FAILURE

Introduction. Kidney damage at the onset of multiple myeloma (MM) is observed in 20–40 % of patients, which requires renal replacement therapy in 2–4 % of cases. Deterioration in kidney function is associated with frequent complications and a decline in the quality of life, as well as carries a high risk of early death.

Aim. To analyze the treatment of patients first diagnosed with MM, complicated by severe and dialysis-dependent renal failure.

Materials and methods. 62 MM patients with a glomerular filtration rate of <30 ml/min /1.73 m2 participated in a retrospective study (11.2014–11.2017) with the following inclusion criteria: the concentration of free light chains in blood serum being >500 mg/l and the selective nature of proteinuria. Diagnosed AL-amyloidosis served as the exclusion criterion. Depending on the need for haemodialysis, patients were divided into two groups: (I) those not requiring it (n = 16) and (II) dialysis-dependent patients (n = 46).

Results. The induction therapy included the following bortezomib-containing regimens: VCD — 41 (66.1 %), PAD — 2 (3.2 %), VD — 12 (19.4 %) and VMP — 7 (11.3 %). High-dose consolidation along with autologous hematopoietic stem cell transplantation was performed in 10 patients (16.1 %). The overall rate of anti-myeloma response in the groups came to 64.3 % (I) and 85.3 % (II) (p = 0.047), including complete and strong complete remissions in 14.3 % (I) and 14.7 % (II) of cases. The renal response was achieved by 57.2 % and 23.5 % (p = 0.032) of patients from the first and second groups, respectively. With a median follow-up of 32.1 months, throughout the entire cohort the median of progression-free survival (PFS) amounted to 14.5 months, with a 3-year PFS of 27.4 ± 6.6 %; whereas the median of overall survival (OS) came to 33.6 months, with a 3-year OS of 41.5 ± 7.7 %. There are no differences between the compared groups in terms of the survival rates. In the examined patients (n = 48), the achievement of any renal response was associated with an improvement in the 3-year PFS — 61.1 ± 11.5 % versus 17.7 ± 7.7 % (p = 0.045) — and 3-year OS — 72,2 ± 10.6 % versus 38.1 ± 10.4 % (p= 0.069). The time elapsed between the first haemodialysis procedure and the onset of anti-myeloma chemotherapy served as the predictor value of the renal response. In the group of patients who achieved a renal response, the average time came to 8.6 (95 % confidence interval of 3.5–13.7) days, as compared to 42.5 (12.6–72.5) days for patients without a renal response (p = 0.045).

Conclusion. The use of bortezomib-based regimens provides a high frequency of antitumour responses with a probability of stopping dialysis in 23.5 % of dialysis-dependent patients. Possible reasons for the low frequency of renal response include the late diagnosis of MM as a cause of kidney damage, as well as the lack of access to new anti-myeloma drugs if the induction therapy needs to be changed. 

[Uromodulin gene polymorphisms in patients with cast nephropathy in multiple myeloma]

AIM

To investigate the nature of mutations in exons 4 and 5 of the uromodulin (UM) gene, including in the area encoding the domain of 8 cysteines (D8C), in patients with multiple myeloma (MM) with the secretion of monoclonal light chains (LC) in cast nephropathy (CN) and without kidney injury.

SUBJECTS AND METHODS

The investigation enrolled 24 patients in MM remission, who were observed to have monoclonal LC secretion at onset. Group 1 included 14 patients with CN; Group 2 consisted of 10 patients with normal renal function (a comparison group). The compared groups did not differ in the number of serum and urinary monoclonal LCs. Genomic DNA was extracted from the peripheral blood samples of patients. The nucleotide sequence of exons 4 and 5 of the UM gene was determined by the Sanger method.

RESULTS

No differences were found in the frequency of polymorphisms depending on the severity of kidney injury. The missense mutation p.142R>R/Q in the UM gene, which had not been previously described, was discovered.

CONCLUSION

The patients with MM were not found to have statistically significant differences in the frequency and nature of polymorphisms of exons 4 and 5 in the UM gene, including in the area encoding D8C, in CN without kidney injury.

[Light-chain deposition disease is a hematologic problem]

AIM

To analyze clinical and laboratory data and treatment results in patients with light-chain deposition disease (LCDD).

SUBJECTS AND METHODS

Nine patients with LCDD and kidney injury were examined. The diagnosis was based on the results of light and immunofluorescence microscopy of renal biopsy specimens. All the patients received bortezomib, cyclophosphamide, and dexamethasone (VCD) induction therapy.

RESULTS

Six patients were diagnosed with multiple myeloma; in 3 patients LCDD was considered within monoclonal gammopathy manly involving the kidney. By the initiation of therapy, all the patients were diagnosed as having chronic kidney disease (Stage III (n=2), Stage IV (n=2), and dialysis-related renal failure (n=5)). After the VCD treatment, 7 of 9 patients achieved a hematologic response. Second-line therapy with lenalidomide proved to be effective in the other 2 cases. Five patients achieved complete remission; 3 had a very good partial remission. Thereafter, 2 patients received high-dose melphalan chemotherapy and autologous hematopoietic stem cell transplantation. Better renal function was noted in only 2 cases.

CONCLUSION

Despite the high efficiency of therapy aimed to reduce monoclonal light chains; improved renal function was observed in only 2 (22%) patients. Such low rates of a renal response were due to the late initiation of therapy.