Many multiple myeloma patients may present with renal (kidney) insufficiency and/or renal impairment.
What Is Renal Impairment?
According to an article titled "Renal, GI, and Peripheral Nerves: Evidence-Based Recommendations for the Management of Symptoms and Care for Patients With Multiple Myeloma" in the October 2017 issue of the Clinical Journal of Oncology Nursing Multiple Myeloma, "the kidneys are vital organs that filter the blood to remove waste materials, balance fluids and electrolytes, release hormones, and eliminate harmful chemicals from the body, including chemotherapeutic drugs. The terms renal impairment and renal insufficiency are often interchangeable and refer to the kidneys' inability to function at the full capacity." Many multiple myeloma patients may present with this complication during the course of their disease. For this reason, clinicians should routinely assess myeloma patients' renal function.
Causes of Renal Impairment in Multiple Myeloma Patients
Renal impairment in patients with myeloma is caused mainly by the toxic effects of monoclonal light chains on glomeruli and renal tubules. Glomeruli are a cluster of capillaries around the end of the kidney tubule. The end of the kidney tubule is where waste products are filtered from the blood.
The most common form of injury to the kidneys in multiple myeloma is cast nephropathy. This complication occurs when an abundance of free light chains plug up the renal tubules. These excess free light chains form aggregates or casts. The casts lead to tubular obstruction and inflammation. Approximately 85% of renal impairment in myeloma patients is related to monoclonal light chains
Comorbidities as Causes of Renal Impairment
More than 15% of renal impairment in myeloma patients is the result of other causes. These causes include
- disease of the arteries
- complications of infection
Other Myeloma-Related Factors That Impair Kidney Function
- hypercalcemia (high blood levels of calcium caused by myeloma-related bone breakdown)
- drugs that are toxic to the kidneys. These drugs include certain antibiotics, non-steroidal anti-inflammatory agents, and myeloma therapies that are excreted by the kidneys.
- contrast agents used in imaging studies (such as gadolinium).
Risk Factors for Renal Impairment
- Advancing age
- Development or worsening of other medical problems
- High multiple myeloma disease burden
- Cumulative toxicity from treatment
Tests of Renal Function
All patients should have the following tests of renal function at diagnosis and at times of disease assessment:
- Serum creatinine
- Urine protein electrophoresis (UPEP) of a sample from a 24-hour urine collection
- Serum free light chain assay (Freelite test)
Treating the myeloma should reverse kidney impairment, sometimes even in a patient who has been in kidney failure and on dialysis. However, longer-term kidney failure is usually not reversible. For dialysis patients, the use of anti-myeloma therapy along with high-cutoff hemodialysis membranes can potentially reverse renal impairment. High-cut hemodialysis membranes allow the removal of free light chains through their large pores. If high-cutoff hemodialysis is not available, plasma exchange may be beneficial.
The standard of care for patients with myeloma and renal impairment are Velcade-based regimens. Velcade can be safely combined with:
- cyclophosphamide and dexamethasone
- doxorubicin and dexamethasone
- thalidomide and dexamethasone
Patients with renal impairment may also take Kyprolis or Ninlaro, the other proteasome inhibitors.
Revlimid is excreted via the kidneys, so the dose of Revlimid must be adjusted according to the degree of renal impairment.
Patients with suspected renal impairment must receive supportive care. This care includes hydration with intravenous fluids and rapid treatment of hypercalcemia. Clinical trials have shown the bone-modifying agent Xgeva (denosumab) is safer than the bisphosphonate Zometa for the treatment of myeloma-related hypercalcemia from bone disease in patients with severe renal impairment. Severe renal impaired is defined as creatinine clearance < 30 mL per minute.
The International Myeloma Foundation medical and editorial content team
Comprised of leading medical researchers, hematologist/oncologists, oncology-certified nurses, medical editors, and medical journalists, our team has extensive knowledge of the multiple myeloma treatment and care landscape. Additionally, Dr. Brian G.M. Durie reviews and approves all medical content on this website.
Last Medical Review: March 1, 2019