Early Reduction of Serum-Free Light Chains Associates with Renal Recovery in Myeloma Kidney

Sophina HissaundFY2

Aims

• Myeloma• The Study• Treatment• Results• Survival• Conclusion• Discussion

Myeloma

• Malignant clonal proliferation of B-lymphocyte derived plasma cells

• A single clone of plasma cells produce identical immunoglobulins seen as a monoclonal band, or paraprotein, on serum or urine electrophoresis

Myeloma Kidney

• Myeloma kidney can cause severe irreversible renal failure in patients with multiple myeloma

• The tubulointerstitial injury is a consequence of high concentrations of circulating monoclonal FLCs produced by a clonal expansion of plasma cells

The Study• To determine the relationship between the achieved early FLC

reduction and renal recovery

• University Hospital Birmingham and Mayo Clinic, Rochester, Minnesota

• 39 patients

• 23 male, 16 female

• Median age 62 years

The Study

• Severe renal failure at presentation

• Biopsy proven myeloma kidney

• 79% first presentation of myeloma

• 15% MGUS before diagnosis

• 24 patients required dialysis support

Treatment

• Birmingham – combination of extended haemodialysis with

thalidomide-based chemotherapy for patients with new presentation of myeloma

– Bortezomib for relapsing disease

Treatment

• Minnesota– Plasma exchange in combination with

chemotherapy regimen consisting of high dose steroids used alone or with Bortezomib, thalidomide, melphalan, vincristine, doxorubicin or alemtuzumab

Results

Day 12 – each increment of 10% FLC reduction was associated with a 60% increase in likelihood of renal recovery

Results

Day 21 –an additional 10% FLC reduction was associated with 60% increased likelihood of recovery

The relationship of reduction in serum FLCs and renal recovery is linear in patients with myeloma kidney

Results

Long Term Survival Outcomes

• Median survival of patients who recovered renal function was 42.7 months

• Risk of death 3x lower for patients with a new myeloma and those with renal recovery

• Patients with λ FLCs had a significant higher likelihood of death

Long Term Survival Outcomes

No significant association between % reduction of serum FLC concentration and survival

Conclusion

• No absolute threshold by which FLCs must be reduced to facilitate renal recovery

• To enable a renal recovery rate of 80%, a 60% reduction in FLC levels by day 21 is required

• Targeting treatment to reverse renal failure in myeloma kidney by early reduction of FLCs is critical

Discussion

• Combination

• Plasma exchange

• Biopsy results

• Pre –existing renal disease

• Small study

Thank you