Kidney embolization induces prompt organ response in a 86‐year‐old patient with MGRS‐related AL‐amyloidosis

Abstract

Despite substantial improvements following the introduction of novel agents and antibodies, amyloid light‐chain (AL)‐amyloidosis still carries a grim prognosis. Here, we report on the case of a severely frail 86‐year‐old patient suffering from monoclonal gammopathy of renal significance (MGRS)‐associated AL‐amyloidosis with a diuretic‐refractory nephrotic syndrome. In this patient, treatment with bortezomib–dexamethasone effectively induced a serological response, but was unfortunately poorly tolerated and failed to promote renal recovery fast enough to prevent secondary complications. Facing ongoing nephrotic syndrome, we performed unilateral kidney embolization and observed a substantial improvement of hypoalbuminemia accompanied by a significant gain in overall quality of life despite the necessity for thrice weekly dialysis. It can be concluded that systemic drugs in MGRS typically do not lead to instantaneous organ recovery but may initially rather be associated with substantial treatment‐related morbidity. In this setting, unilateral renal artery embolization is effective to treat nephrotic syndrome and its secondary complications. The risk of potentially adverse effects, including post‐embolization syndrome, can be minimized by unilateral embolization, still noting that also one‐sided renal ablation has to be balanced against the requirement for life‐long renal replacement therapy. Prospective controlled trials in a more comprehensive cohort will be needed to estimate the overall benefit of kidney embolization relative to novel agent therapies in frail patients with MGRS‐related AL‐amyloidosis.

Structured assessment of frailty in multiple myeloma as a paradigm of individualized treatment algorithms in cancer patients at advanced age

“…before intensive treatment, such as SCT). 11,12,21,[44][45][46][47] If unavailable, smoking status, its mandatory cessation before SCT/intensive treatment, no advanced GOLD criteria, and no dyspnea upon exertion have been used as substitutes in prior analyses. [24][25][26] We have demonstrated the validity of the R-MCI as a valid prognostic instrument in large MM cohorts treated according to current standards.…”

“…For example, since the QoL in a light chain (AL)-amyloidosis patient did not improve, even though hematologic response was achieved, the use of the R-MCI facilitated supportive treatment rather than continuation of extensive and expensive care. 10,46 6. Inclusion of the R-MCI in future study protocols at our center, and in discussion with both German MM study groups (DSMM and GMMG) is under way.…”

Geriatric assessments and frailty scores in multiple myeloma patients: a needed tool for individualized treatment?

“…Assessing frailty, with defined risk scores, should therefore, involve objectively weighted single risk factors, in order to most precisely describe a patient status, as the R-MCI or IMWG-frailty index do. Indeed, the R-MCI combines multivariate risk factors and has been prospectively used in clinical routine and clinical trials, both before therapy and at follow-up to assess patients’ improvement over time [ 14 ▪▪ , 20 , 31 ].…”

Choosing the Right Therapy for Patients with Relapsed/Refractory Multiple Myeloma (RRMM) in Consideration of Patient-, Disease- and Treatment-Related Factors

“…Nevertheless, in RRMM, any fitness assessment is even more important, because numerous relapse regimens exist and their selection is relevant to perform wisely, at best knowing the exact therapy endurance of an MM patient beforehand. Therefore, it is important to assess frailty and comorbidities over the disease course in MM tumor boards regularly and if new treatment decisions are being undertaken [6,[44][45][46][47][48]. The assessment of changing performance status over the disease course was described by us in a reference AL-amyloidosis patient [46], in allogeneic stem cell transplantation-receiving MM patients [47], likewise in ASCT-receiving MM patients [48] and with use of quality of life (QoL) tests in various relapse phases [49].…”

“…Therefore, it is important to assess frailty and comorbidities over the disease course in MM tumor boards regularly and if new treatment decisions are being undertaken [6,[44][45][46][47][48]. The assessment of changing performance status over the disease course was described by us in a reference AL-amyloidosis patient [46], in allogeneic stem cell transplantation-receiving MM patients [47], likewise in ASCT-receiving MM patients [48] and with use of quality of life (QoL) tests in various relapse phases [49]. All of these manuscripts verify that functional performance may change over time and is relevant for treatment decisions.…”