Join us   Log in  


Pages: 234-244
Print Article   Download XML  Download PDF

Multiple Myeloma: a Nephrology Department Experience

Author: S. Mikou, M. Arrayhani, T. Sqalli

Category: JMSR Oncology


Introduction: Multiple myeloma (MM) is defined as a malignant proliferation of a single clone of plasma cells typically accompanied by the secretion of monoclonal immunoglobulins that are detectable in the serum or urine. Renal impairment is present in 50% of patients at diagnosis. The aim of this study is to clarify the clinical, biological and prognosis parameters in patients with renal impairment associate to MM and focus on the economic impacts. Material and Methods: This is a retrospective study of MM with renal impairment cases admitted at the nephrology department of the FEZ university hospital in a period extended from January 2010 to December 2011. The diagnosis is based on Southwest Oncology Group criteria (SWOG) and CRAB activity criteria. The outcome is evaluated according to the criteria of the International Myeloma Workings Group. Results:32 myeloma patients were enrolled for a total of 1250 admissions during a period of two years with 15 women and 17 men. The mean age is 59 ± 10 years. 81 % had impaired general condition and bone pain. 88% of cases had anemia including 1 patient with neutropenia, the acute kidney injury was found in 71% of cases, the need for dialysis was required in 25% of patients. The monoclonal peak is observed in all patients who presented in immunofixation: Ig G 57% of cases and Ig A in 28% of cases. Monoclonal plasma cell infiltration>30% occurs in 50% of cases. The cast nephropathy myeloma is sustained in 53%% of cases. The kidney biopsy is performed in 6 patients and concluded for a myeloma tubulopathy in 2 patients and amylosis in 2 patients. All patients enrolled in our series applied for diagnosis criteria according to criteria established by SWOG in all patients. 80% of patients had bulky disease at both classifications SALMON & DURIE and ISS. 94% of our patients were treated by hydration and alkalization, only 19 % received calcitonin and 53% received biphosphonates for severe hypercalcemia. 50 % of patients were proposed for ALEXANIAN Protocol while 25% were proposed to the VAD (Vincristine-Adriamicyne-Dexametasone) protocol. Renal impairment evolution is dominated by normalization of renal function in 39% of patients. The main complication in our series is infection; it occurs in 53% of cases. Mortality occurs in 44%. The main reasons of death are neurologic complications. In univariate analyisis, the risk factors of occurring death are: age> 60years, ISS stage III. 92.22% of hospitalization cost is provided by the hospital with a mean hospitalization days of 34.5 day/patient for a total of 1105 days. Conclusion: Renal involvement in the MM is common and multifactorial. The realization of kidney biopsy is not always necessary for diagnosis. Prognosis is poor due to high tumor mass (22.7% of deaths). Therapies have been directed to slow the disease progression and to prevent complications.

Keywords: Multiple Myeloma, Renal Impairment, Chemotherapy, Mortality


1. Multiple myeloma. Gautam Raju Mehta, MD, Faten Suhail, MD, Rami Y. Haddad, MD, Ghassan Zalzaleh, MD Edgar V. Lerma, MD. / Disease-aMonth 60 (2014) 483–488.

2. Multiple myeloma. Christoph Röllig, Stefan Knop, Martin Bornhäuser Lancet 2015; 385: 2197–208.

3. Sant M, Allemani C, Tereanu C, De Angelis R, Capocaccia R, Visser O, et al. Incidence of hematologic malignancies in Europe by morphologic subtype: results of the HAEMACARE project. Blood 2010; 5116:3724–34.

4. UK CR. Myeloma incidence statistics 2014. cancer-info/cancerstats/types/myeloma/incidence/ukmultiple-myeloma-incidencestatistics.

5. Patrick Chu. Managing multiple myeloma patients with renal failure Hong Kong Journal of Nephrology (2013) 15, 62e67.

6. S. Manier, X. Leleu; Multiple myeloma: Clinical diagnosis and prospect of treatment. Recommendations of the International Myeloma Working Group (IMWG);Immuno-analyse et biologie spécialisée (2011) 26, 125—136.

7. Meletios A. Dimopoulos a, Evangelos Terpos a, Ruben Niesvizky b, Antonio Palumbo cM.A. Dimopoulos et al. / Cancer Treatment Reviews 41 (2015) 827–835. Clinical characteristics of patients with relapsed multiple myeloma.

8. Abbott KC, Agodoa LY. Multiple myeloma and light chainassociated nephropathy at end-stage renal disease in the United States: patient characteristics and survival. Clin Nephrol 2001;56: 207e10.

9. Van Marion AMW, Lokhorst HM, Van Den Tweel JG. Pathology of multiple myeloma. Current Diagn Pathol 2003;9: 322—7.

10. Greipp PR, San Miguel J, Durie BG, et al. International staging system for multiple myeloma. J Clin Oncol 2005; 23: 341220. 11. Durie BG, Salmon SE (1975). "A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival". Cancer 36. 12. Palumbo A, Anderson K. Multiple myeloma. N Engl J Med. 2011; 364 (11):1046–1060. 13. Facon T, Yacoub-Agha I, Leleu X. Myélome multiple. EMC hématologie 2003, 13-014-E10:15p]. 14. Makni S, Zouari R, Barbouch MR, Ayed K, Moalla M, Zakraoui L. Gammapathies monoclonales en Tunisie. Rev Fr Transfus Hem 1990;33:31—8. 15. A. Bouataya, S. Hizema, Y. Ben Youssefb, F. Sayaria, N. Brahama, Khélif b, M. Kortasa. Multiple myeloma: Clinical aspect, biological diagnosis and prognosis. Immuno-analyse et biologie spécialisée (2013) 28, 30—35. 16. Kyle RA, Gertz MA, Witzig TA, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78: 21—33. 17. Bladé J, Rosinol L. Renal hematologic and infectious complications in multiple myeloma. Best Pract Res Clini Haematol 2005; 18 (4):635—52. 18. Bartl R, Frisch B. Diagnostic morphology in myeloma multiple. Current Diagn Pathol 1995;2: 222—35. 19. Raab MA, Podar K, Breitkreutz I, Richardson PG, Anderson KC. Multiple myeloma. Lancet 2009;374:324—39. 20. Eric Moumas, William Hanf , Estelle Desport, Julie Abraham, Sebastien Delbes, Celine Debiais, Laurence Lacotte-Thierry, Guy Touchard, Arnaud Jaccard, Jean-Paul Fermand Frank Bridoux. New insights in the treatment of myeloma with renal failure. Néphrologie et Thérapeutique 7 (2011) 457– 466. 21. Leung N, Behrens J. Current approach to diagnosis and management of acute renal failure in myeloma patients. Adv Chronic Kidney Dis. 2012;19 (5):297– 302. 22. 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(12):1964– 1968. 23. Knudsen LM, Hjorth M, Hippe E. Renal failure in multiple myeloma: reversibility and impact on the prognosis. Nordic Myeloma Study Group. Eur J Haematol 2000;65:175–81. 24. Kleber M, Ihorst G, Deschler B, Jakob C, Liebisch P, Koch B, et al. Detection of renal impairment as one specific comorbidity factor in multiple myeloma: multicenter study in 198 consecutive patients. Eur J Haematol 2009;83: 519–27. 25. Augustson BM, Begum G, Dunn JA, Barth NJ, Davies F, Morgan G, et al. Early mortality after diagnosis of multiple myeloma: analysis of patients entered onto the United Kingdom Medical Research Council trials between 1980 an 2002 – Medical Research Council Adult Leukaemia Working Party. J Clin Oncol 2005;23:9219–26. 26. Frank W.G. Leebeek Update of thrombosis in multiple myeloma. Thrombosis Research 140S1 (2016) S76–S80. 27. Zangari M, Elice F, Fink L, Tricot G. Thrombosis in multiple myeloma. Expert Rev Anticancer Ther. 2007 Mar;7(3):307-15. 28. Palumbo A, Rajkumar SV, Dimopoulos MA, Richardson PG, San Miguel J, Barlogie B, et al. Prevention of thalidomide- and lenalidomideassociated thrombosis in myeloma. Leukemia. 2008 Feb;22(2):414-23. 29. Vital A. Paraproteinemic neuropathies. Brain Pathol 2001;11:399—407.. 30. Rajkumar SV. Curr Probl Cancer 2009;33:7–64. 31. Durie BG, Harousseau JL, Miguel JS, Blade J, Barlogie B, Anderson K, et al. International uniform response criteria for multiple myeloma. Leukemia 2006;20(9):1467–73. 32. Sanders PW, Booker BB. Pathobiology of cast nephropathy from human Bence Jones proteins. J Clin Invest. 1992;89 (2):630–639. 33. Dimopoulos MA, Kastritis E, Rosinol L, Blade J, Ludwig H. Pathogenesis and treatment of renal failure in multiple myeloma. Leukemia 2008; 22: 1485e93. 34. Clark WF, Stewart AK, Rock GA, et al. Plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial. Ann Intern Med 2005;143:777e84. 35. Hutchison CA, Bradwell AR, Cook M, Basnayake K, Basu S, Harding S, et al. Treatment of acute renal failure secondary to multiple myeloma with chemotherapy and extended high cut-off hemodialysis. Clin J Am Soc Nephrol 2009;4: 745e54. 36. Jagannath S, Barlogie B, Berenson JR, Singhal S, Alexanian R, Srkalovic G, et al. Bortezomib in recurrent and/or refractory multiple myeloma. Initial clinical experience in patients with impaired renal function. Cancer 2005;103:1195e200. 244 JMSR 2016, Vol III ; N°1 :234- 244 Research Article ISSN: 2351-8200 37. Chanan-Khan AA, Kaufman JL, Mehta J, Richardson PG, Miller KC, Lonial S, et al. Activity and safety of bortezomib in multiple myeloma patients with advanced renal failure: a multicenter retrospective study. Blood 2007;109:2604e6. 38. Ludwig H, Drach J, Graf H, Lang A, Meran JG. Reversal of acute renal failure by bortezomib-based chemotherapy in patients with multiple myeloma. Haematologica 2007;92:1411e4. 39. Tosi P, Zamagni E, Cellini C, Cangini D, Tacchetti P, Tura S, et al. Thalidomide alone or in combination with dexamethasone in patients with advanced, relapsed or refractory multiple myeloma and renal failure. Eur J Haematol 2004;73:98e103. 40. Dimopoulos MA, Christoulas D, Roussou M, Kastritis E, Migkou M, Gavriatopoulou M, et al. Lenalimide and dexamethasone for the treatment of refractory/ relapsed multiple myeloma: dosing of lenalidomide according to renal function and effect on renal impairment. Eur J Haematol 2010;85:1e5. 41. Child JA, Morgan GJ, Davies FE, Owen RG, Bell SE, Hawkins K, et al. High-dose chemotherapy with hematopoietic stem-cell rescue for multiple myeloma. N Engl J Med 2003;348:1875e83. 42. Rayner HC, Haynes AP, Thompson JR, Russell N, Fletcher J. Perspectives in multiple myeloma: survival, prognostic factors and disease complications in a single centre between 1975 and 1988. Q J Med 1991;79:517e25. 43. Eleutherakis-Papaiakovou V, Bamias A, Gika D, Simeonidis A, Pouli A, Anagnostopoulos A, et al. Renal failure in multiple myeloma: incidence, correlations, and prognostic significance. Leuk Lymphoma 2007;48:337e41. 44. Kastritis E, Zervas K, Symeonidis A, Terpos E, Delimbassi S, Anagnostopoulos N, et al. Improved survival of patients with multiple myeloma after the introduction of novel agents and the applicability of the International Staging System (ISS): an analysis of the Greek Myeloma Study Group (GMSG). Leukemia 2009;23:1152e7.