Abstract
Myeloma cast nephropathy is a major complication of multiple myeloma. Recent evidence has demonstrated that the earlier induction of bortezomib-based chemotherapy with plasma exchange (PE) provides better results for kidney function and patient survival. Due to its non-selectivity, PE with albumin replacement carries the risk of fibrinogen loss, leading to bleeding. We herein report a case of successful treatment of myeloma cast nephropathy using bortezomib-based chemotherapy and selective PE. A 61-year-old woman who had a 20-year history of type II diabetes mellitus was admitted to our hospital for the evaluation of hypercalcemia, severe kidney dysfunction, and anemia. Subsequent bone marrow evaluation and renal biopsy revealed that she had multiple myeloma (IgG-κ) and myeloma cast nephropathy. Ten days after admission, bortezomib-based chemotherapy with selective PE achieved rapid and thorough free light-chain (FLC) reduction; within a month, her kidney function had been recovered (creatinine level, 1.2 mg/dl). Her serum fibrinogen level was not reduced, and no bleeding complication occurred. Five months later, autologous hematopoietic stem-cell transplantation was performed successfully, and the patient’s kidney function was stable (creatinine level, 1.1 mg/dl) thereafter. This case report demonstrates the importance of early induction therapy with bortezomib-based chemotherapy and PE in a patient with myeloma cast nephropathy, which is especially applicable in patients aged <65 years. In addition, it shows that selective PE is a safe and effective method of FLC removal.
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References
Leung N, Rajkumar SV. Renal manifestations of plasma cell disorders. Am J Kidney Dis. 2007;50(1):155–65.
Huang ZQ, Sanders PW. Localization of a single binding site for immunoglobulin light chains on human Tamm–Horsfall glycoprotein. J Clin Invest. 1997;99:732–6.
Hutchison CA, Batuman V, Behrens J, International Kidney and Monoclonal Gammopathy Research Group, et al. The pathogenesis and diagnosis of acute kidney injury in multiple myeloma. Nat Rev Nephrol. 2011;8(1):43–51.
Nasr SH, Valeri AM, Sethi S, et al. Clinicopathologic correlations in multiple myeloma: a case series of 190 patients with kidney biopsies. Am J Kidney Dis. 2012;59(6):786–94.
Hutchison CA, Cockwell P, Stringer S, et al. Early reduction of serum-free light chains associates with renal recovery in myeloma kidney. J Am Soc Nephrol. 2011;22(6):1129–36.
Burnette BL, Leung N, Rajkumar SV. Renal improvement in myeloma with bortezomib plus plasma exchange. N Engl J Med. 2011;364(24):2365–6.
Ohkubo A, Kurashima N, Nakamura A, Miyamoto S, Iimori S, Rai T. Solute removal capacity of high cut-off membrane plasma separators. Ther Apher Dial. 2013;17(5):484–9.
Durie BG, Salmon SE. A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 1975;36:842–54.
Kim H, Sohn HJ, Kim S, Kim K, Lee JH, Bang SM, et al. New staging systems can predict prognosis of multiple myeloma patients undergoing autologous peripheral blood stem cell transplantation as first-line therapy. Biol Blood Marrow Transplant. 2006;12:837–44.
Hori M, Matsuda T, Shibata A, Katanoda K, Sobue T. Nishimoto H; Japan Cancer Surveillance Research Group. Cancer incidence and incidence rates in Japan in 2009: a study of 32 population-based cancer registries for the Monitoring of Cancer Incidence in Japan (MCIJ) project. Jpn J Clin Oncol. 2015;45(9):884–91. doi:10.1093/jjco/hyv088.
Leung N, Gertz M, Kyle RA, et al. Urinary albumin excretion patterns of patients with cast nephropathy and other monoclonal gammopathy-related kidney diseases. Clin J Am Soc Nephrol. 2012;7:1964–8.
Ying WZ, Allen CE, Curtis LM, Aaron KJ, Sanders PW. Mechanism and prevention of acute kidney injury from cast nephropathy in a rodent model. J Clin Investig. 2012;122(5):1777–85.
Leung N, Gertz MA, Zeldenrust SR, et al. Improvement of cast nephropathy with plasma exchange depends on the diagnosis and on reduction of serum free light chains. Kidney Int. 2008;73(11):1282–8.
Gonsalves WI, Leung N, Rajkumar SV, et al. Improvement in renal function and its impact on survival in patients with newly diagnosed multiple myeloma. Blood Cancer J. 2015;5:e296.
Ludwig H, Adam Z, Hajek R, et al. Light chain-induced acute renal failure can be reversed by bortezomib–doxorubicin–dexamethasone in multiple myeloma: results of a phase II study. J Clin Oncol. 2010;28(30):4635–41.
Schwartz J, Winters JL, Padmanabhan A, et al. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Writing Committee of the American Society for Apheresis: the sixth special issue. J Clin Apher. 2013;28(3):145–284.
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Kawabe, M., Yamamoto, I., Katsuma, A. et al. Successful treatment of myeloma cast nephropathy using bortezomib-based chemotherapy plus selective plasma exchange. CEN Case Rep 5, 232–237 (2016). https://doi.org/10.1007/s13730-016-0231-4
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DOI: https://doi.org/10.1007/s13730-016-0231-4