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Paraprotein-Related Kidney Disease: Evaluation and Treatment of Myeloma Cast Nephropathy

Kevin W Finkel1,2, Eric P Cohen3, Anushree Shirali4

  • 1Department of Medicine, Division of Renal Diseases and Hypertension, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas.

Clinical Journal of the American Society of Nephrology : CJASN
|August 17, 2016
PubMed

Insights

Multiple myeloma patients often develop kidney disease from cast nephropathy. While newer chemotherapy is promising, extended high-cutoff hemodialysis needs more randomized trials before becoming standard care for acute kidney injury (AKI).

Area of Science:

  • Nephrology
  • Oncology
  • Hematology

Background:

  • Multiple myeloma frequently causes renal disease, primarily acute kidney injury (AKI) due to cast nephropathy.
  • AKI in multiple myeloma patients is linked to poor survival and limited treatment choices, highlighting the need for effective therapies.
  • Cast nephropathy arises from filtered free light chains and Tamm-Horsfall protein aggregation, causing tubular obstruction and damage.

Purpose of the Study:

  • To evaluate the role of extracorporeal therapies in managing cast nephropathy and improving renal outcomes in multiple myeloma patients.
  • To assess the potential of extended high-cutoff hemodialysis as a renoprotective strategy by removing serum free light chains.

Main Methods:

  • Review of existing literature on therapeutic plasma exchange and extended high-cutoff hemodialysis for cast nephropathy.
  • Analysis of trial data regarding the efficacy of these extracorporeal therapies in conjunction with novel chemotherapy regimens.
  • Focus on the correlation between rapid reduction of free light chains and renal recovery.

Main Results:

  • Therapeutic plasma exchange showed initial promise in small trials but failed to demonstrate benefit in a large randomized trial.
  • Extended high-cutoff hemodialysis has shown encouraging results in preliminary trials for cast nephropathy.
  • Currently, no randomized trials confirm the benefit of adding extended high-cutoff hemodialysis to modern chemotherapeutic regimens.

Conclusions:

  • Rapid reduction of serum free light chains is crucial for renal recovery in cast nephropathy.
  • While promising, extended high-cutoff hemodialysis is not yet recommended as standard care for multiple myeloma-related AKI pending further randomized trial data.
  • Novel chemotherapy agents demonstrate renoprotective effects by rapidly lowering free light chains.
Keywords:
HCO dialysisHumansImmunoglobulin Light ChainsMolecular WeightMyeloma ProteinsPlasma ExchangeRandomized Controlled Trials as TopicStandard of CareUromodulinacute renal failurecast nephropathyfree light chainsmultiple myelomamultiple myeloma M-proteinsrenal dialysis

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