Revised International Staging System for Multiple Myeloma: A Report From International Myeloma Working Group
The International Myeloma Working Group has developed practical recommendations for the diagnosis and management of multiple myeloma-related renal impairment (RI). These recommendations are based on published data through December 2015 and were developed using the Grading of Recommendation, Assessment, Development, and Evaluation Working Group system. The recommendations aim to provide guidance for clinicians in the evaluation and treatment of renal impairment in patients with multiple myeloma.
Important Points:
- All patients with myeloma should undergo a comprehensive diagnostic evaluation, including serum creatinine, estimated glomerular filtration rate (eGFR), and electrolyte measurements. Free light chain and urine electrophoresis should also be assessed if available.
- The preferred formula for eGFR calculation is the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), or alternatively, the Modification of Diet in Renal Disease (MDRD) formula.
- The International Myeloma Working Group criteria for renal response should be used to assess the reversibility of renal dysfunction.
- High fluid intake (at least 3 L/day or approximately 2 L/m2/day) is recommended along with antimyeloma therapy.
- Bisphosphonates (pamidronate and zoledronic acid) should not be used in patients with severe RI (CrCl < 30 mL/min).
- Denosumab may be useful in patients with hypercalcemia and RI, but calcium levels must be closely monitored.
- Nephrotoxic agents such as aminoglycoside antibiotics, furosemide, and contrast agents should be avoided in MM patients with RI.
- Plasma exchange may be considered for select patients with acute RI or suspected light chain cast nephropathy (CN).
- High-cutoff hemodialysis (HCO-HD) membranes can be used in combination with antimyeloma therapy to reduce free light chains (FLCs) and reverse RI.
- Long-term dialysis is required for end-stage RI, with a response rate to antimyeloma therapy of 40-60% and a median survival time of approximately 2 years.
- HCO-HD in combination with antimyeloma therapy is recommended for patients with acute RI due to CN.
- Plasma exchange may be beneficial for select patients with proven or strongly suspected acute RI related to light chain CN.
- Bisphosphonates should be delayed until GFR has improved in patients with myeloma-related bone disease.
- Plasma exchange combined with bortezomib-based chemotherapy can lead to a reduction in FLCs.
- High-dose dexamethasone, thalidomide, lenalidomide, and autologous stem cell transplantation are effective treatment options for MM patients with RI.
- Carfilzomib and ixazomib can be safely administered to patients with varying degrees of renal function impairment.
- Regular monitoring of renal function and adjustment of treatment regimens based on individual patient characteristics and response is essential in the management of myeloma-related RI.
These recommendations provide valuable guidance for clinicians in the diagnosis and management of RI in patients with multiple myeloma, aiming to improve outcomes and optimize renal function.
Authors:
Antonio Palumbo, Herv Avet-Loiseau, Stefania Oliva, Henk M. Lokhorst, Hartmut Goldschmidt, Laura Rosinol, Paul Richardson, Simona Caltagirone, Juan Jos Lahuerta, Thierry Facon, Sara Bringhen, Francesca Gay, Michel Attal, Roberto Passera, Andrew Spencer, Massimo Offidani, Shaji Kumar, Pellegrino Musto, Sagar Lonial, Maria T. Petrucci, Robert Z. Orlowski, Elena Zamagni, Gareth Morgan, Meletios A. Dimopoulos, Brian G.M. Durie, Kenneth C. Anderson, Pieter Sonneveld, Jesus San Miguel, Michele Cavo, S. Vincent Rajkumar and Philippe Moreau
Citation:
J Clin Oncol 34:1544-1557
DOI: 10.1200/JCO.2015.65.0044