Kidney transplant in multiple myeloma, the challenges, and potentials

Abstract

Kidney failure is a common sequela of multiple myeloma. Tremendous progress in this disease over the past two decades has resulted in more than doubling of the median survival. Despite that, patients with irreversible kidney failure still have inferior outcomes as compared to those with intact kidney function. Kidney transplantation in these patients remains controversial. In this issue of Journal of Onco-Nephrology, two groups of clinicians caring for these patients debate the pros and cons of kidney transplantation in this population. The improvement of overall survival to 7.7 years in patients under the age of 65 years is a strong arg for kidney transplantation. In addition, the use of fluorescent in situ hybridization in risk assessment and minimal residual disease assessment for hematologic response could substantially improve patient selection for kidney transplantation. On the other hand, myeloma remains incurable and kidney failure itself is a high-risk feature. Despite advances, kidney transplantation in myeloma patients continues to present challenges with multiple myeloma relapse, rejection, and infection resulting in higher number of graft loss and death. Whether kidney transplant should be performed in patients with multiple myeloma currently remains debatable, but it may not be long before overall survival and disease control improve to the point where withholding kidney transplantation would be unethical. The questions in preparation for that day are should myeloma patients be held to the same metrics as patients without myeloma and if no, then what would be an acceptable overall and graft survival? Once the answers have been agreed upon by the experts and the governing bodies for transplantation, then proper clinical trials can be designed so that benefits can be optimized and precious resources not be wasted.