This is the second in a series based on “Guidelines for screening and management of late and long-term consequences of myeloma and its treatment” published recently in the British Journal of Haematology. This is one of the most comprehensive resources we’ve found for overall recommendations for living with myeloma as more patients are living longer with the disease and the effects of long-term treatment.
Many myeloma patients struggle with kidney issues (renal function) due to the activity of the myeloma. Here are some suggestions on preventing kidney damage and improving kidney function:
Renal impairment occurs in up to 50% of myeloma patients and is common at presentation. Patients presenting with renal failure are at high risk of early death (Augustson et al, 2005). Causes include cast nephropathy, infection, dehydration, hypercalcaemia, hyperuricaemia and renal involvement with AL amyloidosis, and possibly with use of non-steroidal anti-inflammatory drugs (Bird et al, 2011). Aggressive early management of these factors and urgent treatment of the underlying myeloma often improves renal function. However, even with initial improvement, patients presenting with renal impairment have a higher chance of developing worsening renal impairment at relapse. The risk of irreversible renal failure increases markedly with time.
The sudden onset of blood in the urine, combined with bladder pain and irritative bladder symptoms may be caused by cyclophosphamide or infections, particularly after stem cell transplant, but is usually short-lived and self-limiting. The immune defect in myeloma can make recurrent urinary tract infections problematic; these infections and their treatment can result in further deterioration of renal function.
About 10% of patients need long-term renal supportive therapy, which can have an impact on quality of life (Tariman & Faiman, 2010), the range of available therapies for treatment of the myeloma, and survival. Chronic kidney disease (CKD) can be exacerbated by exposure to intravenous contrast agents and drugs used to treat CMV reactivation. Appropriate dose reductions need to be followed (Pratt et al, 2014) in order to avoid excessive toxicity, such as myelosuppression. Autologous transplant is still a treatment option in patients with renal impairment, but has to be considered in the context of other frailties and comorbidities and with consideration of dose reduction in melphalan (most commonly to 140 mg/m2) (Saunders et al, 2014).
Patients with chronic kidney disease are at a higher risk than other patients of extra-renal complications, such as anaemia, infection and bone loss, which may best be managed collaboratively with specialists in renal medicine. Anaemia can be treated by blood transfusion or erythropoiesis-stimulating agents (ESAs). ESAs are recommended for anaemia in patients with myeloma-associated renal impairment (Locatelli et al, 2004).
- Offer patients information on maintenance of renal health, and promptly investigate any deterioration in renal function not obviously due to myeloma relapse (Grade 1B).
- Routinely monitor patients with chronic kidney disease (CKD) for serum calcium, parathyroid hormone and vitamin D (Grade 1B).
- Investigate anaemia in myeloma patients and monitor long-term for functional iron deficiency (Grade 1C).
- Refer patients with moderate/severe renal impairment (CKD ≥stage 3), renal-related hyperparathyroidism or nephrotic syndrome to a renal specialist (Grade 1C).
- Optimize diabetes and blood pressure control to reduce the risk of progression to end-stage renal disease (Grade 1B).
- Follow recommended dose modifications for lenalidomide and bisphosphonates in the case of renal impairment and avoid nephrotoxic drugs if possible (Grade 1B).
- Consider erythropoiesis-stimulating agents (ESAs) for myeloma-related anaemia, with iron supplementation as necessary (Grade 1B).
To read the full article, click here.