Treatment and prognosis of kidney disease in multiple myeloma and other monoclonal gammopathies
- S Vincent Rajkumar, MD
S Vincent Rajkumar, MD
- Edward W. and Betty Knight Scripps Professor of Medicine
- Mayo Clinic
- Andre A Kaplan, MD
Andre A Kaplan, MD
- Professor of Medicine
- University of Connecticut Health Center
- Nelson Leung, MD
Nelson Leung, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Richard J Glassock, MD, MACP
Richard J Glassock, MD, MACP
- Editor-in-Chief — Nephrology
- Section Editor — Glomerular Diseases
- Emeritus Professor
- The David Geffen School of Medicine at UCLA
- Robert A Kyle, MD
Robert A Kyle, MD
- Section Editor — Plasma Cell Disorders
- Professor of Medicine
- Mayo Medical School
Kidney disease is a common complication in patients with multiple myeloma and other monoclonal gammopathies . A wide range of renal manifestations and pathologies involving different mechanisms have been described with these disorders. Kidney injury most often occurs in patients with a high tumor burden and can evolve as either an acute or chronic disorder .
This topic will review the treatment of kidney disease in patients with multiple myeloma or other monoclonal gammopathies, with a focus on light chain cast nephropathy. The epidemiology, pathogenesis, etiology, clinical features, evaluation, and diagnosis of kidney disease in multiple myeloma and other monoclonal gammopathies are presented separately. (See "Epidemiology, pathogenesis, and etiology of kidney disease in multiple myeloma and other monoclonal gammopathies" and "Clinical features, evaluation, and diagnosis of kidney disease in multiple myeloma and other monoclonal gammopathies".)
The pathogenesis and treatment of amyloidosis and light and heavy chain deposition diseases, and treatment of multiple myeloma, are discussed elsewhere. (See "Pathogenesis of immunoglobulin light chain (AL) amyloidosis and light and heavy chain deposition diseases" and "Overview of the management of multiple myeloma".)
PATIENTS WITH ACUTE OR SUBACUTE KIDNEY INJURY
Acute (AKI) or subacute kidney injury in patients with multiple myeloma and other monoclonal gammopathies results from a variety of mechanisms. These include light chain cast nephropathy, hypercalcemia, nephrotoxic agents (eg, radiocontrast, nonsteroidal anti-inflammatory drugs [NSAIDs]), and, infrequently, hyperviscosity syndrome and severe hyperuricemia. Specific treatment is directed at the cause of AKI [3-8]. Dialysis should be performed for the usual indications. (See "Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose" and "Indications for initiation of dialysis in chronic kidney disease".)
Light chain cast nephropathy (myeloma kidney) — Light chain cast nephropathy occurs most often in patients with high rates of production and excretion of immunoglobulin free light chains, which may be toxic to the tubules and form obstructing tubular casts, particularly if the patient is volume depleted . Light chain cast nephropathy should be treated urgently to restore renal function.
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- PATIENTS WITH ACUTE OR SUBACUTE KIDNEY INJURY
- Light chain cast nephropathy (myeloma kidney)
- - Overview of approach
- - Treatment
- Anti-myeloma therapy
- Fluid management
- Extracorporeal methods for light chain removal
- - Protocol for plasmapheresis
- - Efficacy studies
- - Prevention
- - Prognosis
- - Future directions
- Nephrotoxic agents
- Less common causes of AKI
- - Plasma cell infiltration
- - Hyperuricemia
- - Interstitial nephritis
- - Hyperviscosity
- - Thrombotic microangiopathy
- PATIENTS WITH CHRONIC KIDNEY DISEASE
- End-stage renal disease
- Kidney transplantation
- PATIENTS WITH ALBUMINURIA OR NEPHROTIC SYNDROME
- Monoclonal immunoglobulin deposition disease
- Monoclonal cryoglobulinemia
- Membranoproliferative glomerulonephritis
- Fibrillary glomerulonephritis and immunotactoid glomerulopathy
- PATIENTS WITH ELECTROLYTE ABNORMALITIES
- Light chain proximal tubulopathy (Fanconi syndrome)
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Acute (AKI) or subacute kidney injury
- Albuminuria or nephrotic syndrome
- Electrolyte abnormalities