Recovery of renal function after autologous stem cell transplantation in myeloma patients with end-stage renal failure

Abstract

Summary:The disease-free survival of patients with myeloma and severe renal failure after high-dose melphalan and autologous stem cell rescue is similar to those with normal renal function at the time of the autograft. However, recovery of renal function after intensive treatment is uncommon and patients with end-stage renal failure continue to be dialysis-dependent. We report two patients with myeloma who required regular haemodialysis from diagnosis, but became dialysis-independent after a high-dose melphalan autograft. Thus, in some patients, renal function may be partially salvageable despite the requirement for dialysis at the time of autografting. Bone Marrow Transplantation (2002) 30, 471-473. doi:10.1038/sj.bmt.1703713 Keywords: myeloma; end-stage renal failure; stem cell transplantation There is emerging evidence that patients with myeloma and impaired renal function including those on haemodialysis should be offered treatment with high-dose melphalan (HDMel) and autologous stem cell rescue. 1,2 While renal function can improve after conventional chemotherapy in some patients with renal failure at diagnosis, 3 no significant improvement in renal function has been observed after HDMel. It has been suggested that the renal outcome after HDMel may be related to the type of paraprotein, as well as duration of myeloma. 1 We report two patients with endstage renal failure who became dialysis-independent after treatment with HDMel. Our experience indicates the potential for recovery of renal function after autografting even in patients requiring dialysis. Further studies on mechanisms that cause progressive and irreversible renal damage in myeloma may help identify patients in whom HDMel can potentially restore renal function. Patients Patient 1A 52-year-old male was investigated for a 10-week history of left-sided chest pain. X-rays revealed lytic lesions in the ribs and biopsy was consistent with plasmacytoma. He was anaemic (Hb 7.6 g/l), hypercalcemic (Ͼ3 mmol/l) and in renal failure (creatinine 690 mol/l). There was no serum paraprotein, but light chains were detected in the urine (75.49 g/gCr). The serum ␤2-microglobulin (␤2-M) level was 15.3 and plasma cell infiltrate in the marrow was 25% (stage 3B myeloma). Ultrasound of the kidneys was normal and renal biopsy showed distortion of most renal tubules by casts, surrounded by giant cells. These tubular defects suggested myeloma kidney.A thrice weekly schedule of haemodialysis was started to treat acidosis and volume overload, and the patient received his first cycle of VAD chemotherapy (repeated every 3 weeks) 6 days after the diagnosis. The urinary paraprotein declined to 20.29 g/gCr after two cycles of VAD and re-staging investigations after four cycles of VAD indicated a decrease in marrow plasma cell infiltrate (5%). At this stage his serum ␤2-M and creatinine were 38.7 and 525 mol/l, respectively, and he continued on haemodialysis three times a week. Following the fifth cycle of VAD, peripheral blood stem cells were mobilized with G-CSF (10 g/kg/day...

Efficient Removal of Immunoglobulin Free Light Chains by Hemodialysis for Multiple Myeloma

“…Occasional reports have described late renal function recovery from cast nephropathy. For instance, two patients became dialysis independent after autologous bone marrow transplantation that was many months after their initial clinical presentation with acute renal failure (32). Serum FLC measurements were not reported, but we suggest that the use of high-dosage melphalan had stopped monoclonal FLC production.…”

Efficacy, toxicity and mortality of autologous SCT in multiple myeloma patients with dialysis-dependent renal failure

“…8,10,[12][13][14] It is encouraging, however, that even in patients with severe renal failure, improvements in renal function following transplantation can be observed. 9,[15][16][17] Unfortunately, patients with renal failure appear to have higher rates of treatment-related toxicities and transplantrelated mortality (TRM) compared with patients without renal failure. 9,11,13 In the dialysis-dependent population, it is unclear whether an incremental increase in risk exists and moreover, what patient, disease or treatment-related variables may predispose to this risk.…”

Chronic Dialysis Discontinuation: A Systematic Narrative Review of the Literature in the New Millennium

“…Table II summarizes the 13 case reports retrieved by our search strategy; they deal with one to two cases, and are reported from different sources (8 from Europe, 2 from Japan, 1 from Canada, and 2 from USA). The distribution of the case reports differs from that of the case series and registry data, highlighting the possibility of renal function recovery in immunologic or hematologic diseases, encompassing all the major glomerulopathies, from the rare ones, like Wegener's disease and atypical HUS, to the common ones, like IgA nephropathy or FSGS (29)(30)(31)(32)(33)(34)(35)39). However, in keeping with the important role of vascular diseases in this context, two cases (cholesterol emboli and renal artery stenosis) are also reported (38,41).…”