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Light Chain-Associated Renal Disorders Follow-up

  • Author: Malvinder S Parmar, MB, MS; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Nov 21, 2015
 

Transfer

Patients may require transfer to another center for the following reasons:

  • Dialysis: Ensure early institution of dialysis.
  • Plasmapheresis: Currently, the use of plasmapheresis is justified in patients with rapidly rising plasma creatinine levels and high concentrations of paraprotein.
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Deterrence/Prevention

Maintain adequate fluid intake (2-3 L/d) to avoid dehydration. Dehydration is a common factor that precipitates acute renal failure.

Avoid nephrotoxic agents. NSAIDs, often used to relieve bone pain, are the most prominent offenders.

Ensure early and effective treatment of infections with nonnephrotoxic antibiotics.

Early recognition and treatment of hypercalcemia are important.

Pretreat patients undergoing chemotherapy with allopurinol.

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Complications

See the list below:

  • Renal failure: Renal insufficiency may be indolent, chronic and progressive, or rapidly progressive. Renal insufficiency, a common manifestation of multiple myeloma, is present in more than 50% of patients. In one study, the risk of renal failure was 7% in patients with daily light-chain excretion of less than 0.005 g, 17%, with excretion of 0.005-2 g, and 39% with excretion of more than 2 g.
  • Infections: Infections of the upper and lower urinary tract are common in patients with multiple myeloma because of suppression of humoral immunity.
  • Hyperviscosity syndromes: Measure plasma viscosity in patients with clinical features of hyperviscosity. Urgent plasmapheresis is required in such patients.
  • Renal tubular acidosis
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Prognosis

Factors associated with a poor prognosis in patients with multiple myeloma include the following:

  • High tumor mass (burden)
  • Presence of renal failure (BUN >30 mg/dL, serum creatinine >1.5 mg/dL): Once renal insufficiency is present, the relationship between the degree of renal impairment and the duration of survival is dramatic.
    • With a serum creatinine level of less than 120 µmol/L (1.4 mg/dL), median survival is 44 months.
    • With a serum creatinine level of 120-180 µmol/L (1.4-2 mg/dL), median survival is 18 months.
    • With a serum creatinine level greater than 180 µmol/L (>2 mg/dL), median survival is 4.3 months.
    • Data from the fifth Medical Research Council trial on the treatment of myeloma show that only 50% of patients with a plasma creatinine value of greater than 200 µmol/L (2.3 mg/dL) at presentation were alive after 1 year, compared with nearly 80% of patients with a serum creatinine value of less than 130 µmol/L (1.5 mg/dL).
  • Presence of hypercalcemia (serum calcium >12 mg/dL).
  • Presence of interstitial fibrosis and tubular atrophy based on kidney biopsy findings
  • Pancytopenia: This is indicated by a WBC count of less than 1000/µL, a hematocrit value of less than 30%, and a platelet count less than 50,000/µL.
  • Plasma cell leukemia
  • Previous treatment failure(s)
  • Lambda light-chain disease compared to kappa light-chain disease
  • High beta2-microglobulin level: Levels higher than 6 mcg/mL suggest a worse prognosis (survival of approximately 26 mo) compared to levels of less than 6 mcg/mL (survival of approximately 52 mo).
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Patient Education

Instruct patients to maintain adequate hydration, with a daily oral fluid intake of 2-3 liters, unless fluid restriction is needed because of advanced renal failure.

Warn patients to avoid anti-inflammatory agents because these aggravate renal dysfunction and may precipitate acute renal failure.

Educate patients about the risk of contrast agents that may precipitate kidney failure. They should question the necessity of a contrast imaging study and request alternative studies, if available.

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Contributor Information and Disclosures
Author

Malvinder S Parmar, MB, MS FRCP(C), FACP, FASN, Associate Professor, Department of Internal Medicine, Northern Ontario School of Medicine; Assistant Professor, Department of Medicine, University of Ottawa Faculty of Medicine; Consulting Physician, Timmins and District Hospital, Ontario, Canada

Malvinder S Parmar, MB, MS is a member of the following medical societies: American College of Physicians, American Society of Nephrology, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christie P Thomas, MBBS, FRCP, FASN, FAHA Professor, Department of Internal Medicine, Division of Nephrology, Departments of Pediatrics and Obstetrics and Gynecology, Medical Director, Kidney and Kidney/Pancreas Transplant Program, University of Iowa Hospitals and Clinics

Christie P Thomas, MBBS, FRCP, FASN, FAHA is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, Royal College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.

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Light chain–associated renal disorders. Light microscopy (hematoxylin and eosin stain at 25X power) showing nodular glomerulosclerosis (arrow) and thickening of the basement membrane. Courtesy of Madeleine Moussa, MD, FRCPC, Department of Pathology, London Health Sciences Centre, London, Ontario, Canada.
Light chain–associated renal disorders. Immunofluorescence (25X power) showing deposits of monotypic light chain along the basement membrane. Courtesy of Madeleine Moussa, MD, FRCPC, Department of Pathology, London Health Sciences Centre, London, Ontario, Canada.
Light chain–associated renal disorders. Ultrastructure (electron microscopy at 29,000X power) showing deposition of nonfibrillar electron-dense material in the mesangial nodule (arrow). Courtesy of Madeleine Moussa, MD, FRCPC, Department of Pathology, London Health Sciences Centre, London, Ontario, Canada.
Light chain–associated renal disorders. Ultrastructure (electron microscopy at 29,000X power) showing deposition of nonfibrillar electron-dense material along the basement membrane (arrows). Courtesy of Madeleine Moussa, MD, FRCPC, Department of Pathology, London Health Sciences Centre, London, Ontario, Canada.
Light chain–associated renal disorders. Immunoelectron microscopy (immunogold at 29,000X power) showing kappa light-chain deposition. Courtesy of Madeleine Moussa, MD, FRCPC, Department of Pathology, London Health Sciences Centre, London, Ontario, Canada.
 
 
 
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